
4J | 







r^ 



4+J- 




W Li 



•**>*" 



DISEASES OF CHILDREN 



A TEXT-BOOK FOR THE USE OF 
STUDENTS AND PRACTITIONERS OF MEDICINE 



BY 



C. SIGMUND RAUE, M. E>., 

CLINICAL PROFESSOR OF PEDIATRICS, HAHNEMANN MEDICAL COLLEGE, OF PHILADELPHIA 

VISITING PHYSICIAN TO THE CHILDREN'S WARDS AND CHIEF OF THE CHILDREN'S 

CLINIC, HAHNEMANN HOSPITAL, PHILADELPHIA; PODIATRIST TO THE 

WEST PHILADELPHIA HOMOEOPATHIC HOSPITAL; MEMBER OF 

THE AMERICAN INSTITUTE OF HOMOEOPATHY, ETC. 



SECOND EDITION 
REVISED, ENLARGED AND ILLUSTRATED 



PHILADELPHIA : 

BOERICKH & TAFKL. 

1906. 



LIBRARY of CONGRESS 


Two CoDies Received 


FEB 10 1906 


Q Copyright Entry . 
GLASS (As XXc No. 

I3J* > 3 t 

COPY B. 



COPYRIGHTED 
BY 

BOERICKE & TAFEL. 
1906. 



J. NICHOLAS MITCHELL, M. D., 

FORMERLY PROFESSOR OF OBSTETRICS IN HAHNEMANN 

MEDICAL COLLEGE, PHILADELPHIA ; IN APPRECIATION 

OF THE INSPIRATION OF HIS TEACHING, HIS 

DEEP INTEREST IN PEDIATRICS, AND 

HIS MANY ACTS OF FRIENDSHIP 

TO THE AUTHOR 



PREFACE TO THE FIRST EDITION 



In presenting this work to the profession the author has 
aimed to make it a purely clinical one. 

In the sections on treatment he has endeavored to give his 
own experience as much as possible, and has sought to ex- 
clude all doubtful symptoms and theoretical indications. 

The section on Skin Diseases is from the pen of Dr. Leon 
T. Ashcraft, Lecturer on Venereal Diseases at the Hahnemann 
College. 

In the section on Nervous Diseases, valuable suggestions 
have been made by Dr. Weston D. Bayley, Lecturer on Men- 
tal Diseases and Clinical Instructor in Nervous Diseases at 
the Hahnemann College. 

C. SlGMUND RAUE. 
Philadelphia, 1899. 



PREFACE TO THE SECOND EDITION 



Since the appearance of the first edition of this work seven 
years ago, a number of important discoveries have been made 
in the field of Paediatrics, and some significant changes have 
occurred in the views held at that time regarding the etiology 
and treatment of not a few T of the commonest affections in 
childhood. Furthermore, it is but fair to say that the writer 
himself has felt the need for revising some of his views ex- 
pressed in the former edition, for with riper years and larger 
experience he has learned the value of conservative methods, 
and has endeavored to replace the mere possibilities of thera- 
peutics with clinical certainties. 

The text has been entirely rewritten, and new matter has 
been added wherever it was found desirable to amplify any 
subject. The chapter upon Infant Feeding is practically 
new, and the aim has been to present in a concise and clear 
form the most acceptable and modern views upon this sub- 
ject, which has of late years been made unnecessarily compli- 
cated. A chapter upon Diseases of the Ear, Nose and Throat 
has been added, and illustrations have been inserted wherever 
a picture or a diagram could be advantageously employed to 
elucidate the text. 

I am again indebted to a number of my colleagues for valu- 
able suggestions and friendly cooperation, which, to my mind, 
is necessary in any work covering so broad a field as that of 
Psedriatics. Dr. Chas. M. Thomas has kindlv read the sec- 



Vlll PREFACE. 

tions dealing with the diseases affecting the eyes, the ears, the 
nose and the throat, and has made a few additions to the 
manuscript. To Dr. Wm. B. Van Lennep I am indebted for 
assistance in revising the articles upon Appendicitis and In- 
tussusception, and also for suggestions concerning the treat- 
ment of other conditions, wherever this has presented a surgi- 
cal aspect. Dr. W. D. Bayley has kindly offered some sug- 
gestions relative to Mental and Nervous Diseases. 

For the excellent index I am indebted to Dr. Ernest A. 
Farrington, whose painstaking arrangement of the various 
subjects mentioned and discussed must of necessity add to the 
practical value of the book. 1 have also to thank the pub- 
lishers for their liberality in preparing the many illustrations, 
and for numerous other courtesies. 

I cannot refrain from expressing my appreciation of the 
kind reception which the first edition received at the hands 
of the profession and of the students of our colleges, and 
while my aim has been not to overstep the bounds of a Text- 
Book, I trust that the busy practitioner will find within these 
pages all the practical information which he may need. 

C. S. Raue. 

1626 Walnut St., Philadelphia, Pa. 
February, /po6. 



TABLE OF CONTENTS 



CHAPTER I. 
Hygiene and Nursing. 

Page. 
The new-born — Bathing — Clothing — The month and teeth — Sleep — The 
bowels — Airing — Exercise— Premature and delicate infants — Incu- 
bators — Therapeutic measures — Cold — Heat — Baths — Packs — Nasal 
syringing — Throat spraying — Inhalation — Lavage — Gavage— Irriga- 
tion of the colon — Enemata — Inunctions — Massage 9 

CHAPTER II. 

Mkthods of Clinical Examination. 

Periods of infancy and childhood — Diseases of infancy and childhood — 
Morbidity — Mortality — Growth and development — Diathesis — 
Temperament — Methods of taking history and keeping records — 
Physical diagnosis — Inspection — Palpation — Percussion — Ausculta- 
tion — Pulse — Temperature — Respiration — Urine 30 

CHAPTER III. 

Therapeutics. 

Stimulants— Prescribing — Dosage •. 69 

CHAPTER IV. 

Enfant Feeding. 

Human milk studied in comparison with other milks and feeding mix- 
tures — Milk analysis — Cow's milk — Causes influencing composi- 
tion of breast milk — Modification of cow's milk — Other foods than 
milk — Weaning— Indications for varying percentages of proximate 
principles of infant's food — Intervals for feeding and quantity re- 
quired at different ages — Sterilization of food —Pasteurizing — Prep- 
aration and indication for other foods and adjuvants to child's 
dietary — Artificial foods 77 

CHAPTER V. 

Diseases of the New-born. 

Asphyxia — Cephalematoma — Hematoma of sterno-mastoid muscle — In- 
tracranial Inctnorrhages — Septic and other infections — Acute fatty 



CONTENTS. 

Page. 
degeneration or Buhl's disease — Acute hemoglobinuria or Win- 
kel'* disease — Ophthalmia neonatorum — Mastitis — Icterus neona- 
torum— Oedema — Gastro-intestinal haemorrhage or melena — Gonor- 
rhoea — Sudden death in infants 112 



CHAPTER VI. 
Diseases of the Mouth. 

Dentition — Abnormalities of the teeth — Stomatitis — Catarrhal stoma- 
titis — Pityriasis linguae — Aphthous stomatitis — Bednar's aphthae — 
Aphthae epizooticae — Ulcerative stomatitis — Parasitic stomatitis — 
Gangrenous stomatitis 124 

CHAPTER VII. 
Diseases of the Stomach. 

Acute gastric indigestion — Dyspepsia — Chronic gastric indigestion — 
Nervous dyspepsia — Acute gastritis — Chronic gastritis— Chronic 
gastric catarrh — Cyclic or periodic vomiting — Gastralgia — Malform- 
ations and malpositions — Contraction of the stomach— Dilatation of 
the stomach — Hypertrophic pyloric obstruction — Ulcer of the 
stomach —Cancer of the stomach 137 

CHAPTER VIII. 
Diseases of the Liver. 

Jaundice — Icterus — Cholelithiasis — Acute yellow atrophy — Cirrhosis of 

the liver 177 

CHAPTER IX. 
Diseases of the Intestines. 

vSimple diarrhoea— Acute intestinal indigestion — Acute infectious diar- 
rhoea — Cholera infantum — Acute gastro-enteric intoxication — 
Acute ileo-colitis— Acute intestinal catarrh — Dysentery — Amoebic 
dysentery— Chronic diarrhoea — Chronic gastro-intestinal catarrh or 
mucous disease — Intestinal tuberculosis — Constipation — Acute in- 
testinal obstruction — Intussusception — Appendicitis — Intestinal 
parasites 183 

CHAPTER X. 

Diseases of the periton^eim. 

Acute peritonitis— Chronic peritonitis— Tuberculous peritonitis . . . 248 



CONTEXTS. XI 

Page. 
CHAPTER XL 

Diseases of the Respiratory Tract. 

Spasm of the glottis — Acute catarrhal laryngitis — Spasmodic croup — 
Acute bronchitis — Chronic bronchitis— Asthma — Acute broncho- 
pneumonia — Croupous pneumonia — Pleuro-pneumonia — Pulmon- 
ary tuberculosis — Pleurisy — Empyema 254 

CHAPTER XII. 
Diseases of the Heart and Its Membranes. 

Congenital diseases and deformities — Pericarditis — Endocarditis — Myo- 
carditis — Chronic valvular disease — Mitral stenosis — Aortic steno- 
sis — Aortic regurgitation — Functional disorders 332 

CHAPTER XIII. 

Diseases of the Kidneys and Urinary Tract. 

Albuminuria — Cyclic albuminuria — CEdema without kidney lesion — 
Hsematuria — Hemoglobinuria — Acute nephritis — Chronic ne- 
phritis — Bright' s disease — Chronic parenchymatous nephritis — 
Chronic interstitial nephritis — -Diabetes insipidus — Diabetes niel- 
li tus — Renal calculi — Cystitis — Enuresis — Vulvo- vaginitis — Gonor- 
rluea 3b4 

CHAPTER XIV. 

Diseases of the Skin. 

Inflammations — Eczema — Tetter — Erythema — Furunculosis, boils — 
Impetigo — Impetigo contagiosa — Urticaria, hives — Vegetable 
parasites — Tinea — Tinea tonsurans — Tinea circinata — Ringworm — 
Animal parasites — Pediculosis, lice — Scabies, itch 393 

CHAPTER XV. 
Diseases of the Blood. 

Anaemia — Chlorosis — Progressive pernicious anaemia — Leukaemia — 
Pseudo-leukaemia— Splenic anaemia — Hodgkin's disease — Haemo- 
philia— -Purpura 418 

CHAPTER XVI. 

Diseases of the Nervous System. 

Insanity — Idiocy — Imbecility — Diseases of the brain and its mem- 
branes — Acute leptomeningitis— Tuberculous meningitis — Basilar 
meningitis — Lumbar puncture— Hydrocephalus — Convulsive affec- 
tions—Epilepsy — Tetany — Affections with motor disturbance- 



Xll CONTENTS. 

Page. 

Chorea — Spasmus nutans — Head-nodding with nystagmus — Hys- 
teria — Paralytic affections — Cerebral palsies — Acute anterior polio- 
myelitis — Infantile spinal paralysis — Family ataxia — Hereditary 
spastic paraplegia — Syringomyelia — Multiple cerebro-spinal sclero- 
sis — Multiple neuritis —Symptomatic affections — Neuralgia — Head- 
ache 438 

CHAPTER XVII. 
Diseases of the Ear, Nose and Throat. 

Otitis — Acute catarrhal otitis media — Acute purulent otitis media — 
Acute tonsillitis — Acute folliculous tonsillitis — Ulcero-membran- 
ous tonsillitis — Acute parenchymatous tonsillitis— Peritonsillar ab- 
scess—Hypertrophy of the tonsils — Retro-pharyngeal abscess — 
Acute rhinitis — Pseudo-membranous rhinitis — Simple chronic rhi- 
nitis — Purulent rhinitis — Hypertrophic rhinitis— Atrophic rhinitis 
— Adenoid vegetations of the naso-pharynx 530 

CHAPTER XVIII. 
Constitutional Diseases. 

Ivithsemia — Uric acid diathesis — Rickets — Infantile scurvy — Barlow's 
disease — Status lymphaticus — L,ymphatism — Scrofula — Tubercu- 
lous adenitis — Tuberculosis — Rheumatism— Acute articular rheu- 
matism or rheumatic fever — Hereditary syphilis — Marasmus or 
athrepsia — Malnutrition 567 

CHAPTER XIX. 
Acute Infectious Diseases. 

Exanthemata — Measles— Rubeola — Scarlet fever— Rubella — Variola — 
Varioloid — Vaccinia — Varicella — Pertussis — Parotitis — Influenza — 
Epidemic cerebro-spinal fever — Spotted fever — Malaria — Malarial 
fever — Typhoid fever — Diphtheria — Membranous croup — Intuba- 
tion — Glandular fever 535 



LIST OF ILLUSTRATIONS 



Figure. Page. 

1. Apparatus for feeding premature infants, 15 

2. Infant incubator, . . 16 

3. Method of syringing the nose 20 

4. Steam atomizer, 21 

5. Apparatus for performing lavage, 22 

6. Method of performing lavage, 25 

7. Weight, length, chest and head measurements under twelve months, $2> 

8. Weight, length, chest and head measurements over twelve months, 34 

9. Weight chart for first month of infancy, 35 

10. Weight chart, after Holt, .... 37 

11. Card for recording history of case, 42 

12. Method of determining the character of a spinal deformity, .... 46 

13. Method of obtaining knee-jerk, 49 

14. Method of palpating the lower border of the liver 52 

15. Method of palpating the spleen, . . 53 

16. Diagram showing lower border of lungs and liver, 56 

17. Diagram showing superficial and deep cardiac dulness, 57 

18. Method of holding infant during auscultation, 59 

19. Monaural stethoscope, 60 

20. Binaural stethoscope with large and small chest-pieces, 61 

21. Child of six years; lines showing percussion border of lungs, ... 63 

22. Anterior view, showing apex resonance, deep cardiac dulness, etc., 64 

23. Holt's apparatus for examining woman's milk, 81 

24. Diagram showing percentage of fat in whole milk and set milk, . . 90 

25. Diagram showing fat percentage of different layers of set milk, 91 

26. Freeman pasteurizer, . . . • 102 

27. Arnold steam sterilizer, 103 

28. Diagram showing time of eruption of the milk teeth, 124 

29. Hutchinson teeth, 127 

30. Author's acidometer for estimating acidity of gastric contents, . . . 144 

31. Oxyurisvermicularis, 243 

32. Ascaris lumbricoides 244 

33. Taenia saginata, 245 

34. Head of taenia solium, 246 

33. Spasmodic asthma, 268 

36. Temperature chart in lobar pneumonia, -bowing pseudo-crisis, . . 286 

37. Temperature chart in remitting pneumonia, 287 

38. Lobar pneumonia in child of four years 292 

39. Advanced case of fibro-caseous pulmonary tuberculosis, . . 306 



XIV LIST OF ILLUSTRATIONS. 

Figurk. Page. 

40. Temperature chart in empyema, developing after pneumonia, . . . 322 

41. Skiagraph of child's chest, three years old, posterior aspect, .... 333 

42. Cardiac dulness at one year, six years and twelve years, 334 

43. Acute rheumatic endocarditis with dilatation, 349 

44. Acute nephritis with anasarca and ascites, 371 

45. Chronic parenchymatous nephritis, 375 

46. Method of eliciting Kernig's sign, 440 

47. Method of performing lumbar puncture, ... 461 

48. Hydrocephalus; early period, ... 471 

49. Cerebral diplegia, showing spastic rigidity, .... 514 

50. Climbing up the thighs in pseudo-hypertrophic paralysis, 518 

51. Diagram showing line of incision through the tympanum, . . . . 536 

52. Tonsillotome, 545 

53. Method of holding child for palpating pharyngeal vault, 563 

54. Curette for removal of adenoid vegetations, 566 

55. Child with rickets, showing large head, narrow chest, etc. , . . . . 579 

56. Infant of one year with marasmus, 628 

57. Temperature chart in measles, ... 639 

58. Temperature chart in scarlet fever, 647 

59. Temperature chart in typhoid fever, 705 

60. O'Dwyer's set of intubation instruments, 741 

61. Diagram showing proper position of child in? intubation, 742 



Diseases of Children 



CHAPTER I. 

HYGIENE AND NURSING. 

The New-Born. — Although the care of the new-born be- 
longs, strictly speaking, to the domain of obstetrics, still a 
few practical remarks cannot well be omitted in the introduc- 
tion to the subject of nursing and hygiene of children. 

As soon as the head is born the mouth and eyes should be 
cleansed, the latter being washed out thoroughly with a warm 
boric-acid solution, and this is to be followed by the instilla- 
tion of a drop of a 2 per cent, solution of nitrate of silver, 
according to the method of Crede, if the mother be affected 
with a purulent or specific vaginitis. 

After the cord has been dusted with powdered boric acid 
and dressed in sterilized cotton or gauze the child should be 
wiped dry, the body anointed with sweet oil, especially when 
there is an abundance of vernix caseosa, and wrapped in a 
warm blanket and laid aside until it is convenient to resort to 
the cleansing bath, 

Bathing. — The full bath should not be given until the 
cord has come off, which is usually about the fifth or sixth 
day ; stripping the cord hastens its separation. The child 
should be bathed always in a warm room, preferably before 
an open fireplace. The first bath must be a warm one, ap- 
proximating the normal body temperature ; in hardy children 
it can gradually be reduced, so that a temperature of 95 ° 
F. may be reached, by the end of the sixth month. It 
should be of short duration and the body dried by light rub- 



10 DISEASES OF CHILDREN. 

bing with a soft towel. The bath is best given in the morn- 
ing about one hour after feeding. In children who do not 
react well the full bath must be either prohibited entirely or 
it should be followed by a rapid sponging with alcohol and 
warm water, about one to two dilution. The free use of soap 
is a great mistake, as there is no necessity for the daily use of 
the same, and the irritation of the skin induced thereby often 
excites cutaneous eruptions. 

Clothing. — The material should be of wool ; very light 
weight in summer and heavier for the winter. Grosvenor 
{Present Status of Pediatrics, 1895) speaks highly of the 
princess-cut Gertrude suit, in which the child's organs have 
perfectly free play, no constricting bands being present. He 
also lays stress on the proper construction of the diaper, show- 
ing how the unnecessarily large, old-fashioned muslin can be 
the cause of much harm by overheating the buttocks and 
kidneys and retaining the excreta too closely. A snug fitting 
flannel band about the abdomen is a necessary support during 
infancy, as well as a safeguard against exposure and a pre- 
cautionary measure in children who are prone to diarrhoea. 
In such children it may be worn to the end of the first denti- 
tion period, while in hardy infants it may be discarded after 
the first year. 

The Mouth and Teeth. — Instead of washing the infant's 
mouth after each feeding it is safer to carry out the method 
advocated by Epstein and wash the mother's nipple with a 
solution of boric acid before nursing. There is more danger 
of carrying infection into the mouth in washing the same 
than by leaving it alone, and there is often much harm done 
to the delicate mucous membrane by rough treatment on the 
part of the nurse. Should thrush develop, a mild antiseptic, 
preferably a 2 per cent, solution of boric acid, must be used 
as a mouth-wash. 

The care of the teeth has an important bearing on the 
child's health. Indigestion, enlarged tonsils, cervical ade- 
nitis, and catarrhal affections of the throat and mouth can 



HYGIENE AND NURSING. 11 

often be traced directly to dental caries. Beside these, there 
are many other conditions which show little or no signs of 
improvement until the dentist has been consulted, and all 
source of irritation from carious teeth, dental periostitis, 
overcrowding of the jaw, and the like, has been removed. 

Much trouble can be avoided and the state of the teeth pre- 
served in a sound, healthy condition by the daily use of the 
tooth-brush and early attention to the teeth showing signs of 
caries. There are, however, children in whom the teeth be- 
come brittle or decay in spite of all prophylaxis ; such cases 
require constitutional treatment. 

Sleep. — The healthy babe enjoys a peaceful, undisturbed 
sleep, assuming usually a graceful attitude, indicative of 
complete relaxation. It arouses only to take food, and is 
seldom awake more than one-half to one hour at a time in 
early infancy. After the sixth month the child gradually 
becomes more wide-awake during the day, requiring usually 
two or three naps, and about twelve hours of sleep at night, 
up to the age of two years. From this time on until the 
fourth year it should have at least one nap during the day. 

Children should be carefully trained in regular habits of 
sleep, for if once allowed to develop, the insomnia of infants 
is most stubborn to overcome. The most common causes for 
this disorder are indigestion from over-feeding and the habit 
of nursing during the night, although in children of a nervous 
temperament it may be the result of nervous excitement in- 
duced by playing just before bedtime. Local causes, such as 
seat worms, must also be borne in mind. 

As regards feeding, the first nourishment should be given 
at 5 A. M. and the last at n P. M. ; rarely is it advisable to 
feed during the night, at least not after the fifth month, and 
at the age of two years the child may go without food for 
twelve hours during the night. 

To the observant physician a sleeping infant is an interest- 
ing study, particularly so in case of illness. There are many 
valuable signs of disease, frequently absent during the wak- 



12 DISEASES OF CHILDREN. 

ing state, that become prominent during sleep. As pointed 
out in the chapters on Diagnosis and Treatment, sleep is 
an important element in the recognition of diseases and 
in prescribing. 

The Bowels. — The early training of the child to regular 
habits of stool is of the utmost importance, both from the 
practical and hygienic standpoint. Already in the early 
months of infancy the child can be taught to form the habit 
of emptying the bowels regularly by holding it over a small 
chamber, which can be held between the nurse's knees, and, 
if necessary, irritating the anus by means of a conical piece of 
soap in order to suggest the desire for stool. This should be 
done mornings and evenings and soon the child realizes the 
object of the procedure and the habit becomes established 
without great difficulty, perseverance and regularity on the 
part of the nurse being the key-note to success in obtaining 
such a result. 

Airing. — The nursery should be sunny and well-ventilated, 
no draughts, however, being permissible. If the child is al- 
lowed to crawl on the floor, there must be a carpet in the 
winter, and in the summer matting can be substituted. A 
rug should always be at the door to prevent the draught com- 
ing through the sill and coursing along the floor, which in- 
variably happens when the temperature of the room is higher 
than that of the hallway. For a similar reason it is advis- 
able to have double windows, or at least curtains, in winter, 
as a current of cold air constantly flows down along the 
window-panes, which will surely strike the child if it be al- 
lowed to play or sleep in their vicinity. 

Airing the nursery in winter is best accomplished by hav- 
ing the windows open in the adjoining room until the air has 
been perfectly purified, when the windows should be closed 
and the communicating door opened to allow a diffusion of 
the atmosphere from one room to the other. When the child 
can be removed from the nursery it ma}- be aired like 
any other room. 



HYGIENE AND NURSING 13 

In summer, the room should be kept darkened during the 
heat of the day ; and at sunset, when the outside air has 
cooled off, the windows should be opened, while the child 
may be taken out for an airing. Ordinarily, in the spring 
and fall an infant may be taken out into the fresh air at one 
month and even earlier during the summer. During cold 
weather, however, an infant under three months should not 
be taken out of the house, and after that age only during the 
sunny hours of the day. The precautions necessary to be ob- 
served in taking a child out in its coach are that it be kept 
out of the wind, that it be sufficiently covered and that the 
sun does not shine directly into its eyes, but there is no valid 
objection to allowing a child to sleep in the open air in clement 
weather providing the above precautions be taken. 

Statistics show that infants require a greater amount of air- 
space, proportionately, than adults, and that overcrowding is 
a prolific source of ill-health among children. This is es- 
pecially the case in institutions and hospitals for children. 
Infants require 1,000 cubic feet of air-space in order to thrive ; 
but as they grow older they develop greater resisting power 
to external influences, and may do well under circumstances 
where no more than the above, or even less, breathing-spree 
is available for each child. 

Exercise. — The infant gets its exercise to promote metabol- 
ism in crying and in the non-volitional movements it per- 
forms. It should, however, also have its daily sun-bath and 
airing and it is a good plan, once a day, to allow the infant 
the full and free use of its limbs by removing all tight gar- 
ments and letting it lie upon a bed in this condition for a 
quarter of an hour. Older children require exercise of a 
more definite kind, such as walks in the open air, games, 
etc. A cold sponging every morning aids greatly in the 
physical development of the child. Fatigue and over-exer- 
tion in all forms of sport and exercise are to be strenuously 
guarded against, for the tissues and delicate organs of the 
growing child are far more liable to receive permanent injury 



14 DISEASES OF CHILDREN. 

from their abuse than later in life, when they have become 
accustomed to accommodate themselves to the extra strains 
not infrequently brought upon them. 

Premature and Delicate Infants ; Incubators. — The period 
of viability in a premature babe cannot be exactly stated, as 
the condition of the infant plays a more important role than 
its age. The state of nutrition at birth ; the weight and, 
length ; the condition of the mother during pregnancy and 
above all, the fact as to whether the respiratory function is 
active should rather decide the question of viability than a mere 
arbitrary age limit. The period of viability has been usually 
fixed at twenty-eight weeks, but a number of premature 
infants of twenty-four weeks have been successfully raised. 
Ktheridge {American Text-Book of Obstetrics) suggests that 
any child that breathes at birth should be considered viable. 
Tarnier gives the following statistics based on five years' ex- 
perience with the incubator : Infants of 6 months, 16 per 
cent, saved ; 6% mos., 36 per cent, saved; 7 mos., 50 per 
cent, saved; 7^ mos., ^ per cent, saved; 8 mos., 89 per 
cent, saved; S}4 mos., 96 per cent, saved. This is fully a 
saving of 10 per cent, of lives, as compared with the death 
rate among premature infants not placed in incubators. The 
percentages given by Ktheridge are not quite so high, but on 
the whole quite encouraging. 

An infant weighing less than four pounds and measuring 
less than nineteen inches should be looked upon as pre- 
mature, or at least under-developed, aside from its great 
feebleness and impossibility of maintaining normal body 
heat. These infants possess a digestive tract and respiratory 
organs that are imperfectly developed. The same usually 
holds good with the circulatory organs. Owing to the poorly 
developed state of the muscles, they do not have sufficient 
strength to suckle and deglutition is difficult. The success- 
ful rearing of these infants, therefore, resolves itself into two 
problems : First, the maintenance of the normal body tem- 
perature ; second, the proper mode of nourishment. Owing 



HYGIENE AND NURSING. 



15 



to the rapid loss of heat, strength and weight incident to the 
early days of infancy these children must be cared for from 
the very beginning if we expect to save them. Infants 
weighing three and one-half pounds or over can usually be 
raised outside of an incubator. The body should be wrapped 
in a thick layer of cotton batting instead of attempting to 
dress it. In order to prevent soiling, a 
soft diaper is to be adjusted before wrapp- 
ing up the body. The entire body is 
then wrapped in a blanket and hot water 
bags applied to the feet and sides of the 
body. It is well to rub the child with 
olive oil daily, but it should only be 
washed as often as is absolutely necessary. 
The diet must be that suitable to the 
new-born or even more diluted (see chap- 
ter on Infant Feeding). If breast-milk 
can be obtained, this is, of course, an 
advantage. The milk should be taken 
from the breast with a pump and collected 
in a sterile receptacle. It is then best 
administered to the child with a medi- 
cine-dropper, the milk being dropped 
well back into the pharynx, with the 
child in the recumbent position. Two 
to four drachms of nourishment should 
be given hourly. If the infant cannot be 
made to take sufficient nourishment in 
this manner, gavage must be employed, 
although this procedure is less frequentlv 

indicated in these cases than in the incubator babes. I have 
found that partial peptonization of the food is often an advan- 
tage in premature and feeble infants owing to the under- 
developed state of their digestive organs. Fairchild's Pepto- 
genic Powder answers best for this purpose; it supplies milk- 
sugar to the food besides a small amount, of pancreative and 
bicarbonate of soda. 



FIG. I. — APPARATUS 
FOR FEEDINCx PRR- 

MATrRK INI' A NTS. 
(KOPUK. ) 



16 



DISEASES OF CHILDREN. 




ItMUUiHUUIBIlk. 

jIUBJt'iaiiKU'jiuisiMnHii 



The incubator is a necessary apparatus for maintaining the 
bodily temperature in premature babes. There are a number 

of patterns, each possess- 
ing good points and all 
differing only in minor 
details. The require- 
ments of a good incuba- 
tor are that it should 
maintain a regular de- 
gree of heat, supply the 
infant with a sufficient 
amount of fresh air and 
be readily accessible for 
purposes of changing the 
soiled cotton and for 
gavage. 

The improvements and 
special features found in 
some of the more com- 
plicated incubators are 
advantages, but not ab- 
solute necessities. 

Personally, I have had 
good results with an im- 
provised incubator made 
out of a box with a false 
bottom into which hot 
water bottles may be 
placed and changed as 
they cool off. A ther- 
mometer must be kept 
in the box and the tem- 
perature watched ; it 
should be kept at about 
90 F. A light blanket or shawl may serve as a cover, leav- 
ing the child sufficiently exposed to allow of a free inter- 
change of air. 




FIG. 2. — INFANT INCUBATOR. 



THERAPEUTIC MEASURES. 17 

At the Hahnemann Maternity Hospital Dr. Korndoerfer has 
observed haemorrhage into the spinal cord in two incubator 
babes at autopsy ; the cause of this was probably excessive 
heat. 

Gavage is imperative when the babe cannot take a suffi- 
cient amount by means of the medicine dropper. One to tw r o 
drachms of breast milk or of a 10 per cent, top-milk diluted 
five to six times with a six per cent, solution of milk sugar 
may be administered every hour. If the babe cannot digest 
plain milk, it must be peptonized. 

Exhaustion is averted by handling the child as little as 
possible. Pads of absorbent cotton are more readily adjusted 
and removed than diapers, for which reason they should be 
used, and in place of a full bath a daily rub-down with w T arm 
olive oil is to be given. From two to four drops of brandy in 
twenty drops of sweetened water may be administered as a 
stimulant when necessary. 

THERAPEUTIC MEASURES. 

Cold. — In cold we have one of the best and safest anti- 
pyretics known, beside its well-known analgesic and astrin- 
gent properties. To get the latter effects cold is best applied 
in the form of an ice-bag, a rubber coil through which ice- 
water is allowed to circulate, or cloths wrung out of ice- 
water (cold compresses). Cold is a valuable application in 
most inflammations, but particularly in ophthalmia, meningi- 
tis and synovitis ; as a rule, heat is preferable in inflamma- 
tory affections of the chest and abdomen. Cold compresses 
are useful in croup ; it is contraindicated in diphtheria 
(GooDNO)and in inflammations of the larynx, trachea and 
bronchi (Hoi/r). 

Heat. — Heat is perhaps the most useful of all non-medi- 
cinal therapeutic measures, and has a wide field of appli- 
cability. In painful inflammatory affections it acts promptly 
by relieving tension and hastening resorption. The old- 
fashioned poultice is rapidly being superseded by hot anti- 



18 DISEASES OF CHILDREN. 

septic fomentations in suppurative processes, which do in- 
finitely less mischief than the former. Fomentations pre- 
pared by wringing a piece of spongiopiline or flannel out of hot 
water, best immersed into the same by means of a towel and 
wrung out by winding up both ends of the towel (the water 
should be slightly hotter than the hand can bear), are most 
serviceable when quick results are necessary, as in peritonitis, 
colic, etc. Dry heat is most conveniently applied by means 
of hot-water bags or baked flannel. It must be remembered 
that the child's skin is more sensitive and more readily 
scalded than an adult's, for which reason proper precautions 
must always be taken. 

Baths. — By means of the bath we are able to apply heat or 
cold most rapidly to the entire body. Hot baths are often 
useful in collapse and asphyxia neonatorum ; by adding a 
tablespoonful of powdered mustard to the warm bath we have 
an excellent means of relieving serious congestion of internal 
organs, through its derivative effect, and a harmless method 
of bringing out the rash, especially in cases of measles slow 
in developing. 

The bran bath is most useful in cases of eczema or other 
excoriated conditions of the skin. 

In cases of collapse the child may be placed in a bath of 
ioo° F., which is gradually raised to no°, until reaction sets 
in. 

The action of the cold bath is to reduce the temperature 
and restore the lost tone to the cutaneous vessels, thus in- 
creasing the resistance to the blcod current and improving 
cardiac action ; besides, it gives a powerful stimulating shock 
to the nervous system. For this reason it is of decided value 
in typhoid fever. 

It is best given in the following manner : The child being 
stripped and wrapped in a light blanket, a bath tub filled 
with water at 92 ° F. is brought beside the bed and the child 
immersed by means of the blanket. The temperature of the 
water is then reduced by the addition of cold water to 8o°. 



THERAPEUTIC MEASURES. 19 

While in the bath, friction must be applied to the child's 
body to prevent collapse. The duration is ten minutes, and 
it should be repeated every three hours, reducing the tem- 
perature each time until 75 ° or 70° are reached, continuing 
at this temperature as long as the rectal temperature registers 
above 103 F. (Baruch). 

The cold bath is contraindicated in diphtheria and scarlet 
fever, and in all cases it must be remembered that the child's 
temperature falls more rapidly and more persistently than in 
the case of adults. After the bath it should be dried well 
and rolled up in a blanket if there is chilliness, which is sel- 
dom the case in typhoid fever, but pneumonia patients do not 
stand the cold so well and in these cases a gradual reduction in 
the temperature is always necessary as well as thorough dry- 
ing after the bath. 

Packs. — Packs are highly efficient antipyretics and dia- 
phoretics ; especially is it for the latter effect that they are 
employed. The cold pack is applied by wrapping the child 
in a sheet wrung out of cold water, the sheet being sur- 
rounded by a dry blanket. When used to reduce fever it can 
be reapplied hourly, or more frequently, as necessary. In 
pneumonia the pack is often restricted to the chest. 

The hot pack is most useful in nephritis and uraemia, or 
suppression of urine from whatever cause. A light blanket 
is wrung out of hot water and applied as above, with the dry 
blanket on the outside. 

The hot mustard pack is prepared by adding a little ground 
mustard to the hot water ; it is in many instances preferable 
to the hot mustard bath, and is especially useful in convul- 
sions, congestion of the lungs and of the brain ; also to bring 
out tardy eruptions. While in the pack, the head should be 
sponged with cold water or water and alcohol. 

Nasal Syringing. — This is most important in obstruction 
of the nasal chambers from diphtheric deposits, although 
cases of simple rhinitis frequently require douching to effect 
a prompt cure. The child is placed in the nurse's lap, its 



20 



DISEASES OF CHILDREN. 



legs held between her knees, and the arms and chest con- 
trolled by a towel ; the head is inclined somewhat forward, 
and the blunt nozzle of a douche-bag inserted into one of 
the nostrils. On raising the bag, the irrigating solution 
flows into one nostril and out of the other, being caught in 
a basin held under the child's chin. The nose can also be 
douched with the child lying on its side (Fig. 3). 

Throat Spraying. — The safest and most satisfactory method 
of bringing an antiseptic or oily solution in contact with the 




FIG 3. — METHOD OF SYRINGING THE NOSE. (KOPUK. 



mucous membrane of the pharynx and tonsils is by means of 
the atomizer. Children are late in learning to gargle, and 
even this procedure is not always to be commended, as it is at 
times positively harmful. In case of emergency, however, 
should the child be unruly, cry and not permit the use of the 
atomizer, it can be laid on its back across the nurse's knees, 
with the head thrown back, and the fluid poured into its 
mouth, when it will involuntarily gargle. But in employing 



THERAPEUTIC MEASURES. 



21 



such a method only fluids which can be swallowed with im- 
punity are permissible. 

Inhalation. — The inhalation of steam is very beneficial in 
most respirator}' ailments, but especially so in croup, and after 
tracheotomy it is absolutely necessary. In the absence of the 
specially-constructed u croup-kettle,' ' an ordinary tea-kettle 
in which water is boiling may be used, the steam being 
directed under a sheet overhanging the child in the fashion 
of a tent. The steam atomizer shown in the i^ustration is 
a satisfactory instrument (Fig. 4). 

Lavage. — The apparatus for carrying out lavage in chil- 
dren consists of a soft- 
rubber catheter, attached 
to a piece of rubber tub- 
ing two to three feet long 
by means of a piece of 
glass tubing, and a medi- 
um-sized glass funnel 
which is attached to the 
other extremity of the 
rubber tube (Fig. 5). The 
identical apparatus is also 
used for gavage. For an 
infant three months old I 
use a No. 10, English ; 
six to nine months old, 
No. 11, E., and for an 

older infant, No. 12, E. In the new-born the catheter 
reaches the fundus, when introduced to the length of eight 
inches ; in an infant of three months it must be inserted 
nine inches and in older infants from ten to twelve inches. 
I am in the habit of enlarging the eye of the catheter to 
facilitate the passage of mucus and curds through the same. 

Stomach washing, as an adjuvant in the treatment of gas- 
tric disorders, is a procedure that has long been practiced, but 
its introduction into pediatric practice is due to the efforts of 




FIG. 4. — STEAM ATOMIZER. 



22 



DISEASES OF CHILDREN. 



Epstein, who, in 1883, published a report of 286 cases in 
which lavage was used in gastric disorders in infants with 
great benefit and without a single unfavorable result. Since 
then it has been extensively employed by pediatrists every- 
where. Holt speaks of it as one of the most valuable thera- 
peutic measures we possess, and he states that it has been 
used thousands of times under his directions without any ac- 
cident whatever. While I have never seen an evil result that 

could be traced directly to 
stomach washing, still I feel 
that it has its contra-indication 
as well as advantages, and must 
always be carried out with 
care and caution. It is hardly 
necessary to argue in favor of 
so practical and simple a pro- 
cedure, and to plead for the ac- 
ceptance of a mode of practice 
whose efforts are self-evident 
and whose application is based 
purely on the principles of com- 
mon sense. We have always 
recognized that in toxic cases 
the first rule is to apply the 
stomach-pump. Since we have 
learned that most cases of 
acute indigestion and all cases 
of cholera infantum are toxic 
in origin, it becomes our duty 
to immediately empty the stomach under these conditions 
unless nature has helped herself and free emesis has set in. 
The passage of a tube into the infant's stomach is, as a rule, 
accompanied by no depression and only slight discomfort, 
which is not to be compared to that resulting from severe 
nausea or artificially-induced vomiting. By this method we 
not only empty the stomach, but we are also able to wash 




FIG. 5. — APPARATUS FOR PER- 
FORMING LAVAGE. 



THERAPEUTIC MEASURES. 23 

it out thoroughly and remove every vestige of harmful matter 
and abnormal secretions, in consequence of which, recovery 
from an attack of acute gastritis is more prompt than under 
ordinary circumstances. Besides, remedies are better able to 
act when taken into a clean stomach than in one containing 
decomposing food and mucus. 

It is not, however, only in acute conditions in which lavage 
is of benefit ; in subacute and chronic gastritis, fermentative 
dyspepsia and dilatation of the stomach, it has proven very 
useful. Daily lavage for the purpose of removing tenacious 
mucus that interferes with the digestive process, or for draw- 
ing off undigested food and gases where they have accumu- 
lated, is a most valuable adjuvant in the treatment of chronic 
gastritis and dilatation. These conditions are by no means rare, 
as anyone having extensive practice among children knows. 

Lavage is highly recommended to allay gastric irritability 
and control distressing vomiting associated with obstruction 
of the bowels. In acute gastritis with uncontrollable vomit- 
ing there is no method of treatment so efficacious as lavage. 

I wish to refer to another use to which the stomach tube 
may be put with great advantage, namely, for the purpose of 
putting food into the stomach. It may seem uncalled for to 
administer food in this manner, but the clinical experience 
upon which it is based fully justifies it. The most rebellious 
stomach retains several ounces of food poured in through a 
tube when a teaspoonful taken by the mouth will be im- 
mediately vomited. Kerley has brought this fact out 
prominently, and he explains it on the grounds that the pas- 
sage of the tube causes less irritation of the pharynx than the 
food in being swallowed. Formerly, lavage was only used in 
the rearing of premature infants, as suggested by Tarnier, and 
in grave acute diseases when the child refused or was unable 
to take food or drink, — a condition commonly encountered 
in gastro-intestinal inflammation. 

The results of lavage in the conditions above enumerated 
are positive. For the last few years I have tested it practically 



24 DISEASES OF CHILDREN. 

both in my hospital work and private practice and my ex- 
perience has led me to look upon it as indispensable in the 
treatment of these maladies. I have seen many cases of 
gastro -enteric catarrh, and some of gastric dilatation, diag- 
nosed as marasmus (which, by the way, is a symptom, and 
not a disease), promptly display a tolerance for the proper 
food and assimilate it after the institution of systematic 
lavage. That it was a life saver in many of these cases I am 
bold to claim. 

The infant, being held upright, seated on the nurse's lap, 
should be covered with a towel, to prevent soiling the cloth- 
ing, and the catheter then inserted in the pharynx with the 
right hand, its tip following the index ringer of the left hand, 
which presses down the base of the tongue (Fig. 6). Wetting 
the catheter with plain water is sufficient, as a rule, on account 
of the free secretion of mucus in the pharynx, which acts as 
a lubricant ; but if there be abnormal dryness of the mucous 
membrane, there is no objection to the use of a little diluted 
glycerine. The child may make efforts at deglutition as soon 
as the catheter reaches the pharynx, in which case it glides 
down into the oesophagus easily. More frequently, however, 
it gags, interfering with the operation. If we now wait for a 
few seconds, until the child draws a long breath, a gentle push 
will readily force it into the oesophagus. All that is then 
required is to pass the catheter along with the fingers, which 
can be done without changing the position of the hand, until 
it reaches the stomach. This usually takes place when about 
ten inches have passed ; and, if the stomach be full, some of 
its contents will escape through the apparatus when its end is 
lowered. In fact, the catheter can be felt to strike the fundus 
of the stomach, and after a little experience one can readily 
tell just where the tip of the catheter is located. It is well 
to first raise the funnel to allow the escape of gas, which is 
often present. It is then lowered over a basin, and held there 
until the stomach contents are drained off. Frequently 
nothing will come from the stomach until water is poured in 



THERAPEUTIC MEASURES. 2o 

through the funnel and a siphon established. Again, the 
gastric contents may be so thick or tenacious as not to flow 
through the tube until diluted and broken up. With the 
funnel held a distance of two feet above the level of the epi- 
gastrium, two to four ounces of plain boiled water at ioo° F. 
are poured in, and before the last part of the water has flowed 




FIG. 6. — METHOD OF PERFORMING LAVAGE. 



in, the tube is pinched, in order to maintain a continuous 
column throughout the tube. The funnel is then lowered 
into the basin and the stomach contents siphoned out. This 
procedure is repeated until the fluid comes out clear. 

It is often advantageous to leave a few ounces of water in 
the stomach ; in case of vomiting, pour the feeding in before 



removing the tube. 



In acute gastritis hot water at no° F. is 



26 DISEASES OF CHILDREN. 

more advantageous, and when fermentation of food is a promi- 
nent symptom a i per cent, solution of boric acid may be 
used instead of plain water. I am also in the habit of using 
bicarbonate of soda when the gastric contents contain lactic or 
butyric acid. In carrying out gavage the same steps are taken, 
with the exception that the child is kept in the prone position 
throughout. The removal of the tube must be quickly done, 
at the same time pinching it to prevent the fluid from run- 
ning into the pharynx and larynx, thus setting up gagging 
or a coughing paroxysm. 

The contra-indications for lavage are pulmonary or cardiac 
diseases, with cyanosis or embarrassment of respiration, ex- 
treme debility, and ulceration of the stomach. Exceptionally, 
we encounter forms of gastritis in which the passage of the 
tube causes slight bleeding from the stomach, leading one to 
suspect ulceration, — post-mortem examinations, however, 
showing the mucous membrane intact. In such a case it is, 
of course, imperative to desist. Occasionally, also, we en- 
counter an infant in which attempts at passing the tube cause 
much distress, embarrassed respiration, and prostration. 
With great care it is often possible to carry out the introduc- 
tion of the tube ; but it should not be long retained, and if 
after-effects are to be noted it is not wise to persist. The 
great majority of cases, however, do not mind the tube in the 
least, and some hardly seem to realize its presence, giving one 
ample opportunity to wash the stomach. Caution is, never- 
theless, always necessary ; and the child must be carefully 
watched while passing the tube, while it is in position, and 
after the operation. 

Gavage, or forced feeding, is often necessary during the 
course of an acute illness and in certain forms of indigestion, 
when the child refuses to take nourishment, or is unable to 
do so or is unconscious. In these cases the food is introduced 
while the child is in the recumbent position, care being taken 
to keep it quiet after the operation. In cases of persistent 
vomiting, food introduced by means of the tube is often 



THERAPEUTIC MEASURES. 27 

retained. Premature infants are in many instances raised by 
gavage, when they would otherwise have succumbed without 
its employment. 

Irrigation of the Colon and Enemata. — For simply empty- 
ing the rectum the enema is all that is required, but where it 
is deemed advisable to flush out the entire tract of large in- 
testine it is necessary to resort to irrigation of the colon. The 
enema is administered by laying the child upon its back with 
the thighs flexed upon the abdomen and inserting the nozzle 
of a hard-rubber syringe, well lubricated, into the anus. 
Where soap and water have been decided upon for the injec- 
tion, it is better to use a small fountain syringe, elevated 
three feet above the child's hips. The hard-rubber syringe 
is preferable where such substances as sweet oil or glycerin 
are employed. The glycerin should always be diluted with 
three parts water ; of this, one ounce may be used. 

For irrigating the colon the child is placed on its left side 
upon a rubber sheet covered with muslin or linen, the hips 
being slightly elevated. A soft-rubber catheter, No. n or 12, 
English, is attached to the nozzle of a fountain syringe, 
lubricated, and carefully inserted into the rectum. The 
water is then allowed to flow in slowly, stopping the stream 
as the child makes efforts at expulsion. The catheter must 
be passed through the sigmoid flexure as the water begins to 
flow and distend the rectum. The fluid will usually reach 
the colon without difficulty, but cannot pass into the ileum, 
although it is claimed that if the colon is not distended, and 
the water allowed to flow in slowly, a closure of the ileo- 
cecal valve does not take effect, and so the fluid may even 
reach into the small intestines. However, if the larger 
bowels are thoroughly cleansed we have accomplished our 
end. After a half to one pint of fluid has run in, the amount 
being gauged according to the age of the child, it should be 
allowed to escape by removing the nozzle from the catheter, 
and the process repeated until the fluid comes out clear. 
Tepid water, 80 ° to 90 ° F., answers best for ordinary irriga- 
tion ; boric acid may be added (2 per cent.), if desired. 



28 DISEASES OF CHILDREN. 

Irrigation of the colon is useful in diarrhoeas, especially if 
the stools are offensive or contain an abundance of mucus or 
undigested, irritating particles. The same technique is em- 
ployed when distention of the bowels with water is used as a 
means of relieving intussusception. Hot injections have been 
used in collapse and cold in hyperpyrexia, but the latter pro- 
cedure is entirely uncalled for. Enteroclysis is a safe and effici- 
ent means of averting circulatory failure in acute infectious 
conditions. When a hot normal saline solution is employed 
it stimulates the abdominal sympathetic nerves and also 
supplies the tissues with water. The blood pressure is 
promptly raised and elimination of toxines through the kid- 
neys hastened. When the blood pressure is high and the 
heart chambers are over-filled it is not wise to resort to this 
procedure. Enteroclysis is properly carried out by inserting 
a Kemp's flexible double current catheter high up into the 
rectum and allowing water at 105 to no° to flow through 
for ten to fifteen minutes. In hyperpyrexia the water should 
be used at 85 ° to 90 ° to bring down the temperature. It is 
well to leave as much water in the bowel as will remain 
when removing the catheter. 

Inunctions and Massage. — The nutritive value of oil inunc- 
tions renders this form of treatment of great usefulness in all 
cases of malnutrition and wasting diseases. Beside the direct 
nutrition resulting from the absorption of the oil or fat, there 
is also a decided stimulus imparted to the entire nutritive 
process by the friction and kneading of the surface. For this 
reason it really encroaches upon the field of massage, from 
which it borrows a most useful therapeutic measure. Inunc- 
tions of an animal fat, such as benzoinated lard, not only 
relieve itching, but also act antipyretically in scarlet fever. 
They are valuable in any form of fever with dry, hot skin. 

Massage is perhaps more limited in its field of usefulness in 
diseases of children when compared with its applicability in 
adults, but, nevertheless, there are many conditions in which 
it must always remain indispensable. 



THERAPEUTIC MEASURES. 29 

After the bath it is well to apply general massage to the child, 
especially if it be of a delicate constitution and slow to react. 
During the cold or graduated bath it is necessary to employ 
it to keep up peripheral circulation. 

Effleurage and Petrissage (stroking and kneading), together 
with passive motion of the joints, especially the smaller ones, 
are the procedures employed in the above conditions. 

General massage is often of great value in cases of malnu- 
trition, anaemia, most constitutional diseases, and especially 
in nervous diseases. " It becomes almost a necessary adju- 
vant in the functional nervous conditions in which over-feed- 
ing, combined with rest, forms the principal therapeutic 
means, and in organic nervous diseases generally, to promote 
local and general nutrition." (Bartlett.) 

Massage of the abdomen is a valuable adjuvant in the treat- 
ment of chronic constipation. The warmed hand is placed 
upon the abdomen in the region of the umbilicus, and under 
gentle pressure rotary movements are executed for a few 
minutes. The hand is then passed from the right iliac 
region upwards, following the direction of the colon, across 
the abdomen, and down on the left side, repeating the pro- 
cedure several times. In this way friction is directly applied 
to the walls of the intestine, and a displacement of their con- 
tents in the normal direction is effected. 



CHAPTER II. 

THE METHODS OF CLINICAL EXAMINATION. 

The Periods of Infancy and Childhood ; Morbidity and 
Mortality. — Infancy may be divided into three distinct 
periods, namely, the new-born, the period of early infancy 
and the dentition period. No sharp boundary lines can be 
drawn to separate these periods into distinct stages, as this 
classification is purely arbitrary and exists only for the sake 
of conveniently studying and grouping certain physiological 
and pathological peculiarities belonging to them. 

Infancy may be said to terminate with the completion of 
weaning, and, although the entire teething period (twenty- 
four to thirty months) is sometimes spoken of as u infancy," 
still the majority of pediatrists consider this terminated at the 
end of a year, when the child should be able to take a certain 
amount of solid food and plain cow's milk. Childhood begins 
from this time on and extends up to the period of puberty 
(twelfth to fourteenth year in females ; fourteenth to sixteenth 
year in males). Childhood, again, is divided into early child- 
hood, or the milk-tooth period, occupying the first to sixth 
year and later childhood, the sixth to twelfth year, during 
which time most of the permanent teeth erupt and physical 
and physiological processes more closely attain to the adult 
type. 

The Diseases of Infancy and Childhood. — While in many 
instances it is correct and permissible to speak of diseases of 
children, still a large number of diseases encountered in child- 
hood are but the ordinary ailments that affect all mankind in 
general. Their course, however, is so modified by the imma- 
ture or exaggerated anatomical structure and physiological 
activity of the child's economy that they differ in many 
respects from the type of the disease as seen in adults. Croup- 



THE METHODS OF CLINICAL EXAMINATION. 31 

ous pneumonia, typhoid fever, enteritis, etc., belong to this 
group. Capillary bronchitis, spasmodic croup, the exan- 
themata and a number of other contagious diseases belong 
almost exclusively to the period of childhood, while rickets 
and hereditary syphilis are distinctly diseases of children. 

The new-born is particularly susceptible to septic infection 
on account of the open state of the umbilicus and the delicate 
nature of the epidermis. Besides, there are distinct patho- 
logical conditions belonging to this period. They are spoken 
of as the diseases and malformations of the new-born {Neona- 
torum). 

The young infant is particularly susceptible to mycotic 
disease of the mouth {thrush) owing to the absence of normal 
buccal secretion. It may also develop capillary bronchitis 
or contract whooping cough or succumb as a result of con- 
genital debility, hereditary syphilis or early tuberculous in- 
fection. 

The teething period predisposes to gastro-intestinal de- 
rangements, although in this period of infancy a large num- 
ber of infants succumb to broncho-pneumonia. Disturbances 
of nutrition belong to this period — marasmus, rickets, 
scurvy. 

Childhood proper gives us the largest number of acute in- 
fectious diseases. The intermingling of children on the 
street and at school explains the prevalence of contagious dis- 
ease at this period of life. 

Mortality. — Nearly 10 per cent, of all infants die during 
the first month of life (Eross). From a study of the death 
reports of New York City, Holt found that about one-fourth 
of all deaths occur during the first year of life and nearly one- 
third during the first two years. The causes for this high 
mortality are mainly congenital debility, improper feeding 
and the infections. 

The largest number of deaths occurs from gastro-intestinal 
diseases, which are most fatal in the hot summer months. 
They furnish about 35 per cent, of deaths. Next conic the- 



32 DISEASES OF CHILDREN. 

acute diseases of the respiratory tract, 21 per cent. Other 
prominent fatal diseases are whooping cough, 12 per cent. ; 
congenital syphilis, 10 per cent. ; measles, 9 per cent. (Ash- 
by and Wright.) 

Growth and Development. — The rate of increase in the in- 
fant's weight is a safe criterion for judging of its progress, 
while continued loss in weight possesses distinct diagnostic 
significance. Absence of the regular weekly gain in weight 
implies improper feeding providing there are no signs of 
disease present. When not directly traceable to insufficient 
nourishment or indigestion we should suspect the advent of 
marasmus, or the beginning of a tuberculous meningitis, or 
general infantile tuberculosis. 

Progressive increase in weight cannot, however, be looked 
upon as an invariably favorable sign. It is well known that 
syphilitic infants often look fat and well nourished, but may, 
nevertheless, die very unexpectedly. Budin (Annates dn Med. 
et de Chir., June, 1900) has observed that infants suffering 
from various acute disorders may gain in weight suddenly 
and then die iu the course of a few days. In some of these 
cases there is localized oedema and deficient urinary excre- 
tion. In febrile disturbances he has also noted increase in 
weight at times. 

Hand in hand with increase in weight there should also be 
a regular increase in length in the normally developing in- 
fant. According to Schmid-Monnard there is an increase in 
length of three-quarters of an inch per month during the first 
year. The male new-born measures 50 cm. in length ; the 
female, 49 cm. 

During the first two months of life there is a gain of from 
3 to 4 cm. ; in the following three months, 2 cm. ; and in 
the last months of the first year, 1.5 cm. At the end of the 
first year the total gain is 19 to 23 cm. ; at the end of the 
second, 10 cm., and during the third year, 7 to 8 cm. The 
male slightly exceeds the female in length (Monti). 

The head has a greater circumference than the chest at 



THE METHODS OF CLINICAL EXAMINATION. 



33 



birth ; at the middle of the first year the measurements begin 
to approximate each other and at the end of the year the 
chest grows larger than the head. A comparison of the cir- 
cumference of the head with that of the chest, therefore, 
offers important clinical data. In rickets the head is some- 




LENQTH 



20.7 



WEIGHT 
7LBS.12 0Z, 



NEWBORN 




LENGTH 



26.2 



WEIGHT 
15.4 LBS. 



6 MOS. 



FIG. 7. 




LENGTH 



27.7 



WEIGHT 
18 LBS. 9QZ. 



12 MOS. 



what larger than normal while the chest is abnormally small. 
In hydrocephalus the head is unusually large and the chest 
normal, while in microcephalia the head is proportionately 
much smaller than normal. 

The diagrams shown in the illustrations (Figs. 7 and 8) have 
been constructed from the results of measurements of 200 



34 



DISEASES OF CHILDREN. 



healthy infants by Hedlicka and Pisek (Chapin's Theory and 
Practice of Infant Feeding, pp. 306 and 307). 

The initial weight, roughly stated, may be said to double 




length 




29.8 



LENGTH 



WEIGHT 
22 LBS. 2 OZ. 



32.0 



18M0S. 



WEIGHT 
24 LBS. 



24 MOS. 



FIG. 8. 



itself in five months and treble itself at the end of the first 
year. During the first four months the babe gains half a 
pound per week ; this gradually falls off until there is from 



THE METHODS OF CLINICAL EXAMINATION. 3o 

one-half to one-third of that amount of weekly gain. The 
average infant weighs seven and one-half pounds at birth, 
losing half a pound during the first week. Xot until the 

HAHNEMANN HOSPITAL— Maternity Department 
WEIGHT CHART 

Nimt Color Stx Date of Birth 190 



DAY V»EL« 


. 


-V 


-: 


: 


7 


■ 


c 


;:• 


[] 


12 


13 


14 


15,1s 


17|l8|l9 


;.: 


21 


22 


23 


o • " ... 


..: 


..■ 






■! 


WEEK . DAY 


MOUTH CAY 




1 




















































day '.'.;-.:•-; 


4010 1 

■" : :>- 

57&33 

■~^: : 

55565 
5443 1 
S5Z<J1 
SZ'bi 

49805 
48761 

46493 


■ — 
3 

z 


oz 

1 

8 












= 


= 












1 


=1= 




1 


= 




= 




_^i_- 


i 


- 


= 


u_ 


,_ 


oz 
S 

.. 
_^ 

j^ 

12 
I 
4_ 

12 

8. 
4. 

H 


__ 

JO 


iRMS 

.-.. ,- 

61234 

60101 

58967 

r ; - : 

56699 

55565 

5443 1 

53297 

52163 

51029 

-.: 

48761 

47627 

44493 

B3! 

44tt5 


v::-i. 

4K'J7 

- ■■:.-■ 
3%69 
3855 5 
37421 
KOI 
3515 5 
34019 

3175.1 
30617 
£9483 
28349 
27215 
£6081 
£4947 
23813 
22679 
5T0C 


, 9 

5 

L.! 


! 

12 
8 
± 

VL 

4 

IT 
^~ 

12 

8 
: 


' =' : -^ 


^Tcgi 


















- 




— 


~ 




~~ 






~ 


I 


8 
i_ 

;." 
S 
4_ 

~~~ 

1 

i. 
•} 

B 


2_ 

7. 

■ T 


43091 
419X7 
r 408zl 
39689 
38555 
37421 
36287 
35153 
34019 
3288.5 

31751 
30617 
29183 
2834 9 

;-j < 

. :•' 1 

24947 
23813 
2267.9 

JOL5 


URINE ■ 










































= URINE 


















































■■• 












1 



































PIG. 9. — HAHNEMANN HOSPITAL, MATERNITY DEPARTMENT, WEIGHT 
CHART FOR PIRST MONTH OF INFANCY. 

eighth or tenth day does it regain its birth-weight. At the 
Hahnemann Maternity Hospital it has been the rule- for the 



36 DISEASES OF CHILDREN. 

average normal babe not to regain its birth-weight until after 
ten days. The accompanying chart is used at that institu- 
tion for recording the daily weight (Fig. 9). 

Holt has constructed a weight chart (This chart is pub- 
lished by Geo. L. Goodman & Co., 55 Fulton St., New York 
City, and has on its reverse side spaces for recording the diet 
from month to month, Fig. 10), which is indispensable for 
accurately recording the weight and obtaining the weight 
curve. The normal weight curve is indicated on the chart 
and by this we can gauge the progress of the case. In older 
children the average weight at the various aees is about as 



r s : 

AGE. 


HEIGHT. 


WEIGHT. 


Birth 


20 in. 


V/z lbs. 


5 nios. 


24 iii. 


15 lbs. 


1 year 


29 in. 


21 lbs. 


2 yrs. 


32 in. 


26 lbs. 


3yrs. 


35 in. 


31 lbs. 


4 yrs. 


38 in. 


' 35 lbs. 


5 }' r s. 


40 in. 


40 lbs. 


6 yrs. 


43 in - 


44 lbs. 


7 yrs. 


45 in. 


48 lbs. 


8 yrs. 


47 in. 


53 lbs. 


14 yrs. 


60 in. 


100 lbs. 



The fontanels offer positive indication of the progress of 
development. Normally the posterior fontanel is obliterated 
at the end of the second month, while the anterior closes from 
the sixteenth to the eighteenth month. Ordinarily, delayed 
closure of the anterior fontanel indicates malnutrition or 
rickets. When bulging is associated with separation of the 
cranial sutures the cause is more likely to be hydrocephalus. 

Muscular development. At three to four months the babe 
attempts to grasp objects and can hold up its head. By the 
seventh month it should be able to sit erect, and before it is 
a year old it should make voluntary- efforts to support the 
weight of the body with its legs, i. e., stand with slight assist- 
ance. Walking is as a rule attempted at the end of a year. 
The ability to walk unassisted should not be delayed beyond 



THE METHODS OF CLINICAL EXAMINATION. 





■**i[kl 
L.Em 

Nam< 


nrtt HcU. M. C. 


Cm 


1 Jurine thtjlrlt 

o ******** 






INFANT'S WEIGHT CHART 

55 fuito. stkct, Ntw tom Date of Birtn 




































Uir «U UIMhH ,H». 






WEEK OF AGE. 




„ 


1 3 .". 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 89 11 43 4n 17 49 ?1 




S 
M 

n 

B 
21 

M 
16 

u 

17 

ie 

M 

13 
12 
11 
10 
9 
6 
7 
1 
i 










































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































s 


*> 




































































































*• 






































































































<* 




































































































y 


s 


































































































r- 


*» 


























































































































































































































































































































































































































































































































































































































/ 






































































































' 






































































































/ 








































































































V 






































































































/ 








































































































/ 








































































































t 














































































































































































































/ 








































































































/ 








































































































/ 








































































































/ 




























































































i 












/ 








































































































/ 








































































































/ 






































































































\ 


/ 








































































































™ 
























































































































































































































































































































































































































































































































































































































































I 




3 MONTHS 6 MONTHS • MONTHS 



FIG. lo.— WKICHT CHART, AFTER HOLT. 



38 DISEASES OF CHILDREN. 

the eighteenth month. If so, malnutrition or rickets should 
be suspected. 

Talking begins coincidently with walking. As a rule, girls 
begin earlier than boys. At the age of two years a child 
should be able to put words together intelligently. Aside 
from tongue-tie — a rare condition — the causes delaying the 
development of speech are either constitutional enfeeblement 
or some mental defect (see chapter on Nervous and Mental 
Diseases). 

The physiological and anatomical peculiarities distinctive 
of the period of childhood will be discussed in the introduc- 
tory remarks to the chapters dealing with the various organs 
and systems. 

Diathesis ; Temperament. — Much stress was formerly laid 
on the value of the diathesis as an important element in diag- 
nosis, and teachers of pediatrics attempted to classify the 
various constitutions into definite types, each of which showed 
pronounced predisposition to certain diseases. It was held 
that the scrofulous diathesis, for example, was a distinct form 
of constitution in which there was a tendency to suppurating 
affections of the lymphatics certain skin diseases, predis- 
position to catarrhal affections, croup and meningitis, and a 
number of other constitutional disturbances, among which 
enlarged tonsils and adenoid vegetations stood prominently. 
The condition was not clearly understood until it was discov- 
ered that scrofula, so-called, was in reality tuberculosis of the 
lymphatics. A tuberculous diathesis was also spoken of, in 
which there was a strong predisposition to pulmonary tuber- 
culosis and other acute forms of the disease. We know now 
that tuberculosis may affect any child that has been exposed 
thereto, as many authenticated cases demonstrate ; and, while 
there is no doubt that certain individuals are more susceptible 
to the tubercle bacillus than others, still the so-called tuber- 
culous diathesis is nothing more than a frailty of constitution, 
and has no other significance. 

It is improper to speak of a syphilitic diathesis, as is some- 



THE METHODS OF CLINICAL EXAMINATION. 39 

times done, because a person either has syphilis or has it not, 
there being no proof that such a thing as natural predisposi- 
tion, any more marked than the universal predisposition of 
all mankind, exists. On the other hand, if syphilis be 
inherited, the patient is immune to acquired syphilis. 

The rheumatic diathesis has been described, but there is 
still confusion in the minds of the profession as to what is 
really meant by this term. To the writer's mind, this dia- 
thesis occupies at present the position formerly occupied by 
the scrofulous diathesis, which we now fully understand. 
Speaking of the hereditability of rheumatism, Bartlett says : 
" The hereditability of rheumatism is universally conceded. 
And yet the present popular view that it is an infectious dis- 
ease will probably do much to modify this opinion. The 
difficulties can be reconciled by assuming that there is a 
special diathesis favoring the incidence of rheumatism, and 
that this is transmitted from parent to child. It is also sug- 
gested that the poison upon which rheumatism depends is the 
special agency which is transmitted. Still others assert that 
it is some particular anatomical or structural peculiarity 
which is responsible." (A Text-Book of Clinical Medicine.) 

It will therefore be seen that it is unsafe, in the present 
state of our knowledge of diathetic conditions, to place too 
much importance on this feature of a case, or to go beyond 
the teachings of Bouchard, who divides constitutions into 
the arthritic, or a predisposition to certain diseases in 
which the process of nutrition is retarded (rheumatism, gout, 
diabetes, cholelithiasis, etc.), and scrofula, in which there is a 
predisposition to tuberculosis. The writer has faithfully en- 
deavored to demonstrate to his entire satisfaction that the 
study and recognition of the diathesis is an important clin- 
ical datum, but he has not been convinced that this is always 
the case. (Hahn. Monthly, Feb., 1903.) 

The following description of the various diatheses is given 
for the sake of acquainting the student with the characteris- 
tics held to be sui generis of these types of constitution. 



40 DISEASES OF CHILDREN. 

The scrofulous child is stout and flabby, and is subject to 
glandular enlargements and catarrhal conditions of the mu- 
cous membranes and skin; the features are usually coarse, 
the temperament phlegmatic, and the cerebral faculties dull. 

The tuberculous or phthisical child is of an active tempera- 
ment, bright and precocious ; the frame is sparely developed, 
the skin delicately transparent, the hair generally soft and 
silken. 

The syphilitic infant is recognized by the hoarse cry, the 
snuffles, ulcerated nasal septum, the characteristic eruptions, 
especially in the groins and about the anus, and the old, 
withered look, due to malnutrition. Later in life we notice 
the broad, flat root of the nose, the linear scars about the 
angles of the mouth, Hutchinson's teeth, interstitial keratitis, 
and many other possibilities. Of course, it is unreasonable 
to expect to find all of these signs in every case of hereditary 
syphilis, but careful examination will usually detect sufficient 
of them to clinch the diagnosis. 

The rachitic child is typical in appearance. When well 
developed there is the characteristic square head, the epi- 
physeal enlargements, the beading of the ribs, bowing of the 
long bones, pot-belly, enlarged spleen, profuse sweat about 
the head, anaemia and constipation. In abdominal tubercu- 
losis we also have the large belly ; but here the small chest, 
the wasted thighs and the absence of typical rachitic mani- 
festations will easily differentiate the two. 

Rheumatism is more extensive in its areas of distribution 
in children than in adults. The joints are not, as a rule, so 
severely affected as the endocardium and nervous system. 
Tonsillitis, with fever and aching in the limbs, is often the 
only outward manifestation of an acute attack of genuine 
rheumatism, during the course of which the heart is often 
involved, or chorea follows as a sequel. The rheumatic dia- 
thesis, therefore, often presents itself by nothing more than 
the common joint-pains, often called growing pains; urinary 
disturbances, pointing to incomplete oxidation and elimina- 



TAKING A HISTORY AND KEEPING RECORDS. 41 

tion of excreta; a general retardation of the nutritive pro- 
cesses, from which gravel and biliary calculi may result; 
anaemia ; subcutaneous fibrous nodules ; chorea and endocar- 
ditis, and certain forms of cutaneous eruptions. 

METHODS OF TAKING A HISTORY AND KEEPING 
RECORDS. 

The importance of intelligent, systematic case-taking and 
the keeping of accurate records cannot be overestimated. By 
using the card system the physician can keep a single set of 
records, including both his office and outside work, for it is a 
simple matter to carry a few cards in one's visiting list, and 
thus take notes at the bedside of the patient. 

The first part of the history comprises the data obtained by 
interrogating the child or the attendant upon the child. 
After this has been recorded the results of the physical ex- 
amination and such remarks as the physician finds of direct 
bearing on the case (prognosis, diagnosis, treatment) are added 
thereto. 

The schema shown in Fig. 1 1 is a reproduction of the card 
used in the children's department of the Hahnemann Hos- 
pital Dispensary. The significance of the data sought and 
the means by which they are best obtained are as follows : 

The family history is inquired into for the purpose of de- 
termining whether there is an hereditary disease or hereditary 
predisposition. Sometimes, as in the case of tuberculosis, it 
is difficult to say whether heredity or exposure to a tuberculous 
relative plays the most prominent part in the case. Inquiry 
should be made regarding tuberculosis in parents or their im- 
mediate relatives. A history of syphilis can at times be ob- 
tained by a frank admission of the parents, but often they 
will not only deny the same but even evade skillfully applied 
interrogations aimed at establishing such a history. Rheu- 
matism should also be inquired into, as there is no doubt that 
certain diseases are based upon a special diathesis favoring 
the incidence of rheumatism (see ante). Atavism, the ten 
4 



42 DISEASES OF CHILDREN. 

dency of certain diseases, notably tuberculosis, to reappear 
after having skipped a generation, must also be taken into 
consideration. Mental and nervous diseases in the parents or 
immediate relatives should be noted. Temperamental pecul- 
iarities and neurotic tendencies may be augmented in the 
child through the intermarriage of near relatives. 

The health of the other children and their number may 
throw much light upon the family history. Marasmus com- 
monly appears when the mother has had a large number of 



No 


CHILDREN'S DEPARTMENT 


HAHNEMANN HOSPITAL DISPENSARY. 


Name 


Date 


Address 


Nativity 


Age 


Occupation 


Diagnosis 




HISTORY: 




Health of father 




" " mother 




" " other children 




Mode of birth 


Dentition 


Food 




Previous illnesses 




Present environment 




Present illness 





Fig. ii. 

children in close succession. A history of miscarriages, to- 
gether with stillborn children or the death of preceding 
children in the early months of infancy from "inanition," 
point strongly to maternal syphilis. 

The mode of birth may account for the presence of birth 
palsies (protracted labor, especially breech cases). 

It is of prime importance to learn whether the child was 



TAKING A HISTORY AND KEEPING RECORDS. 4-3 

breast fed or artificially fed. Improper artificial feeding is 
the cause of the various nutritional diseases, such as rickets, 
marasmus, scurvy and gastro-intestinal catarrh. It may also 
be the origin of tuberculosis. Unsuitable breast-milk and 
prolonged lactation, however, not infrequently bring on 
rickets. Note what the present food is. 

Xote the time at which the teeth made their appearance 
and whether dentition progressed steadily or with interrup- 
tions; also the time of walking and talking. Dentition, 
walking and the state of the fontanels are indices of the 
physical development of the child, while talking is an im- 
portant index of mental development. 

Previous illnesses. Has the child had the various infec- 
tious diseases? Name them to the mother individually. As 
most of them occur only once in a lifetime, a doubt in the 
diagnosis is at once removed if the child has already had the 
disease we may be suspecting. Vaccination must not be for- 
gotten. Aside from the question of immunity we must also 
consider that certain diseases have sequelae or predispose 
to other diseases. Thus, measles and w T hooping cough pre- 
dispose to tuberculosis ; scarlet fever may leave nephritis or 
chronic suppurative otitis, and the latter may be the cause of 
some obscure intracranial condition (cerebral abscess, throm- 
bosis). Convulsions in infancy may terminate in epilepsy in 
later childhood. Diphtheria may be followed by paralyses 
of various kinds. 

EnmronmenL Aside from offering a source of infection, 
environment may affect the child's constitution to a marked 
degree. The squalid, sunless tenement houses furnish ample 
cause for anaemia and rickets, even tuberculosis. Children 
raised in the country rarely develop rickets. Overwork at 
school or an exacting teacher may be the etiologic factor in 
chorea. Again, many vicious habits are directly attributable 
to environment. 

The present illness is now recorded. Inquire into the 
child's health before the first signs of the ailment showed 



44 DISEASES OF CHILDREN. 

themselves. Determine whether there were prodromata and 
whether the disease developed slowly or abruptly. Exactly 
how many days has the child been ill? If there is fever, 
since when, and has the fever been continuously high, remit- 
ting, or intermitting? What other important symptoms are 
present — vomiting, diarrhoea, constipation, cough, pain? If 
there is pain, where does the child refer the pain to, and is it 
aggravated by motion? Has the child complained of sore 
throat? 

In describing the stools, inquire into their size and fre- 
quency, color, odor. Is mucus, blood or undigested food- 
matter present? Is there pain before, during or after the 
stool ? 

Having completed the interrogation of the case, the find- 
ings of the physical examination according to the methods 
detailed below are then added in clear and concise terms, to- 
gether with the findings in the urine, sputum and blood when 
called for. 

For facilitating the recording of physical signs rubber 
stamps giving the outlines of the front and posterior aspect 
of the trunk are very convenient. The diagram is simply 
stamped upon the record card, and by means of lines and 
arbitrary signs to indicate the outlines of organs and path- 
ological findings a graphic representation of the case is 
obtained for future reference. These stamps can be obtained 
at most surgical instrument houses. 

PHYSICAL DIAGNOSIS. 

Inspection is the first step in the examination of a sick 
child. What has been discussed in the previous section 
should be put to practical application in beginning the study 
of a case, and so the diathesis, temperament, state of develop- 
ment and nutrition, and individual peculiarities of the patient 
are first to be noted. If the child be of the tuberculous dia- 
thesis, presenting the constitution and temperament peculiar 
to the same, we naturally suspect the possibility of pulmonary 



PHYSICAL DIAGNOSIS. 45 

mischief ; or, if such a child complains of a pain in the knee, 
we immediately turn our attention to the hip-joint rather than 
consider the pain to be of rheumatic origin, in which case we 
would expect to find other prominent evidences of rheumatism. 

To inspect the child satisfactorily it must be stripped and 
viewed from front and back, both standing and reclining. 

The diathesis having been noted, the development of the 
framework should next demand our attention. Is the child 
emaciated ? If so. in what particular locality is this most 
marked ? The prominent belly, small chest and wasted 
thighs have been referred to. 

The color of the skin is important to note. Normally, in 
the infant it is pink, and anaemia is not difficult to recognize. 
Eruptions must be looked for, eczema and syphilis being the 
most common conditions encountered at this period of life. 
In cardiac and pulmonary 7 disease, and especially in mem- 
branous croup, cyanosis is to be observed. Jaundice also is a 
condition often seen in the new-born and is not foreign to 
childhood. Miliaria and sudamina are common in rachitic 
children, especially in summer. By drawing the finger-nail 
across the skin a red streak will be left, indicating an insta- 
bility in the vaso-motor nerves. It is very pronounced in dis- 
ease of the central nervous system, for which reason Trousseau 
attempted to establish this symptom pathognomonic of 
meningitis. The phenomenon is known as tache cerebrate. 

If there be deformity of the spine, we must determine 
whether it is due to Pott's disease, rickets, a unilateral pleural 
effusion, old pleuritic adhesions, or lack of muscular develop- 
ment. The child should be laid flat upon its stomach and 
the body then partly lifted from the table by making traction 
on the feet. If rachitic, the deformity is at once reduced by 
the traction, but the kyphosis of Pott's disease is irreducible 
under all methods of manipulation (Fig. 12). Retraction of 
the chest from pleuritic adhesions produces scoliosis, and in 
these cases we can get the history of a former empyema as 
well as confirmatory physical signs in the thorax. 



46 DISEASES OF CHILDREN. 

The head presents many peculiar features of prominent 
diagnostic value. In rickets it is large and square ; in hy- 
drocephalus large but rounded, the fontanelles are widely 
open, and the eyeballs displaced downwards. In rickets there 
are often parchment-like areas representing a thinning out of 
the bony elements, known as craniuiabes. The osseous nodes 
of syphilis are very characteristic. 




FIG. 12. — METHOD OF DETERMINING THE CHARACTER 
OF A SPINAL DEFORMITY. 

The. facial expression often points to the seat of trouble ; for 
instance, the knitting of the brows in headache, which when 
associated with squinting, is a strong presumptive sign of 
meningitis ; the fan-like motion of the alse nasi in respiratory 
troubles, and the pinched expression of the face in abdominal 
disease. Roughly speaking, it can be said that the upper 
part of the face represents cerebral, the mid-portion respira- 



PHYSICAL DIAGNOSIS. 47 

tory, and the lower portion abdominal disturbances. Often 
one cheek will present a circumscribed redness, which is said 
to correspond to the side affected in pneumonia. Personally 
I have seen it change from side to side. In severe pulmon- 
ary infiltration or congestion and in some forms of heart dis- 
ease the obstruction to the circulation will become manifest 
by networks of enlarged capillary vessels seen on the cheeks 
(also on the chest, and sometimes on the palms of the hands). 

The chest may present deformities, peculiarities of the ribs, 
deviations from the normal respiratory movements, abnormal 
movements, and various skin eruptions. In the early stages 
of pleurisy the painful side becomes fixed and may produce a 
certain degree of scoliosis. As the effusion is poured out the 
side bulges. In chronic pleurisy with adhesions the side be- 
comes permanently retracted. The intercostal phonation phe- 
nomenon of Stiller {Wiener Med. Wochenschr., No. 15, 1902) 
is a bulging or elevation of the lower intercostal spaces seen 
when the patient is made to enunciate sharply words of short 
syllable. It is due to a wave of air propagated down the 
bronchial tree as the air is being forced through the narrowed 
glottis. This wave is transmitted to fluid effusions in the 
pleural sack, but the sign is absent when pulmonary consoli- 
dation is present. 

In rickets the sternum is prominent from lateral compres- 
sion of the costal cartilages {pectus carinatuni), and the path- 
ognomonic beading of the ribs, the "rickety rosary," is often 
present. In phthisis that portion of the chest over the 
consolidated lobe is flattened and does not move in the same 
degree as the unaffected side ; the clavicle stands out promi- 
nently, and there is often marked retraction of the ribs (flat- 
tening) in that region. 

In emphysema the chest assumes a rounded fullness, slight 
motion only being perceptible during respiration. After peri- 
carditis with adhesions the intercostal space is often seen to 
retract distinctly during the heart's diastole, but more im- 
portant than this is Broadbenf s sign, i. e., systolic retraction 
of the lower ribs posteriorly on the left side. 



48 DISEASES OF CHILDREN. 

The spine has been referred to. Spina bifida must not be 
overlooked. 

The limbs and joints must be examined for evidences of 
arthritis or tuberculous joint troubles ; the fibrous subcuta- 
neous nodules pathognomonic of rheumatism ; the deformi- 
ties of rickets, rheumatism, and poliomyelitis anterior ; the 
bone affections of syphilis and tuberculosis. The limbs will 
also give evidence of the various forms of paralysis likely to 
occur in childhood, and of rachitic pseudo-paralysis. 

The reflexes. Among the superficial reflexes the plantar 
is of especial importance. Under normal conditions a flexor 
response is obtained, but in lesions of the pyramidal system 
hyperextension of the great toe occurs. This is spoken of as 
Babinski's sign. In infants up to the age of learning to walk 
the response is somewhat similar to the Babinski phenome- 
non. The great toe is drawn back ; the toes are extended 
and spread out and the foot is everted. The Babinski sign is 
more deliberate, however, and there is but a small amount of 
movement at the ankle. 

The knee-jerk is exaggerated in lesions affecting the upper 
neurons or irritating the lower neurons. Diminished or 
abolished knee-jerk indicates lesions in the lower neurons. 
In children it is best obtained in the dorsal position with the 
foot resting on the palm of the left hand, striking the tendon 
with a percussion hammer held in the right hand (Fig. 13). 

Ankle clonus indicates disease in the spinal cord, from the 
first to third sacral segments. 

The position assumed by the child during sleep and waking 
is important to note. We see the child burying its head in 
the pillow in cerebral inflammations ; lying on the back with 
limbs drawn up in abdominal inflammations ; on the affected 
side in acute pleurisy ; the head drawn back and the spine 
arched during opisthotonos ; unable to lie in the prone posi- 
tion in the dyspnoea of capillary bronchitis; impossibility 
of extending the leg upon the thigh when in the sitting pos- 
ture owing to contraction of the flexor muscles, which disap- 



PHYSICAL DIAGNOSIS. 49 

pears when the dorsal decubitus is assumed {Keriiig^s sign in 
meningitis) ; sleeping or comatose ; crying out in sleep and 
gritting the teeth. During natural sleep the child assumes 
an easy, graceful position, indicating complete relaxation ; 
the respiration is of the abdominal type. 

The character of the cry is often a hint in diagnosis. The 
shrill, piercing cry of meningitis is pathognomonic. The 
hoarse cry heard in the absence of croup points to syphilis. 
In otitis the cry is often continuous, in spite of all that is 




FIG. II. — METHOD OF OBTAINING KNEE-JERK. 

done to humor the child. The recognition of the cry of hun- 
ger, pain and temper is more readily attained by observation 
than from reading. The natural cry is a loud, strong vocal 
effort accompanied by reddening of the face and does not last 
more than a few minutes. Abnormal cries are as a rule 
weaker in character and more persistent. The cry of pain 
may be strong, but it is accompanied by evidences of suffering 
and distress, such as facial contortions, drawing up of the legs, 
bringing the hand to the affected part, etc., and it is more or 



50 DISEASES OF CHILDREN. 

less persistent. The cry of hunger is a continuous fretful 
cry, ceasing when food is offered. The cry of temper is loud 
and is accompanied by all the signs of anger, such as kicking 
and striking about. During serious illness the cry becomes 
feeble and partakes more of the nature of fretting. 

The inspection of the throat is left until the last on account 
of the struggles and resistance of the child usually induced 
thereby. It should be done quickly and thoroughly, and all 
preparations relative to the examination must be made before- 
hand. Taking the child into a good light, or in some cases 
a head mirror may be used, it is seated upon the nurse's lap 
or held in her arms, the head slightly thrown back, and the 
handle of a spoon pressed down firmly on the base of the 
tongue. This is very often followed by gagging or a violent 
expulsive effort, but if we are quick we have seen enough. 
The gagging brings to view every part of the fauces, it being 
desirable to gain access to the lateral regions. In contagious 
diseases we should be prepared for the sudden cough which 
is likely to occur and spurt mucus or pieces of membrane into 
our face. Often nothing more will be necessary 7 than to allow 
the child to cry, during which act a satisfactory view of the 
mouth and throat is obtainable. We must cultivate the habit 
of taking in the whole picture at a glance and retaining the 
impression long enough to analyze it, otherwise much val- 
uable time will be spent in bungling efforts. 

Palpation. — The sense of touch, when properly trained, 
will give more information in the study of sick children than 
is generally supposed. The first thing that strikes our atten- 
tion as we touch the child's body is the temperature, and 
with a little practice this method of judging of the degree 
of fever becomes accurate enough for man}- cases. We 
should observe whether the heat is uniform, or whether one 
part of the body is hotter than another, for the head may be 
considerably hotter than other portions of the body ; in the 
later stages of entero-colitis the abdomen will be hot, while 
the extremities may be decidedly cold. 



PHYSICAL DIAGNOSIS. 51 

In palpating the head we determine the state of the fon- 
tanels, whether they be delayed in closing or prematurely 
closed, whether bulging or depressed. We also look for 
craniotabes, exostoses, and any evidence of sensitiveness of 
the scalp or ears, this often hinting at middle-ear disease 
when other prominent signs are wanting. If this sensitive- 
ness to touch be general, it marks the advent of rickets 
(Jenner). 

From the head we can descend to the chest, taking in the 
neck on our way down, where we often find scrofulous en- 
largement of the cervical glands. Often, however, no definite 
sequence can be followed out, and we must avail ourselves of 
an opportunity presented by the child either crying, ceasing 
to cry, or finding it in a sound sleep, to proceed at once to 
palpate the abdomen, which can only be done satisfactorily 
during complete relaxation. 

In an examination of the chest palpation is usually the first 
step, and if the child will accommodate us by crying we can 
judge of the vocal fremitus. The child should be held by 
the mother in such a manner that it rests on one of her shoul- 
ders and presents its back to the physician. The hand is 
placed on the back in order to determine vocal fremitus, and 
the rattling of mucus in the bronchi is distinctly transmitted 
to the hands, in bronchitis. The hands can then be placed 
on the sides of the chest and the respiratory movements of 
both sides compared. The left hand will now seek the car- 
diac area, by which means hypertrophy or a thrill can often 
be detected. 

Auscultation should follow next in chest examinations, for 
the disturbance induced by percussion may be so great as to 
hinder any further progress in the case. 

The abdomeii is most satisfactorily palpated while the child 
is asleep, the warmed hand being gently introduced under the 
bed-covering. Distension or retraction of the abdominal wall 
was noted while inspecting. The trained palpating hand 
will recognize enlargement of the liver and spleen (Figs. 14 



52 DISEASES OF CHILDREN. 

and 15); the presence of enlarged mesenteric glands; friction 
between the abdominal wall and the organs; impacted 
fecas, etc. 

Tenderness in certain regions and rigidity of the recti mus- 
cles is of diagnostic significance. Thus, tenderness over 
McBurney's point and rigidity of the right rectus is pathog- 
nomonic of appendicitis. Gurgling in the right iliac fossa 
together with tenderness is strong presumptive evidence of 
typhoid fever, but not a pathognomonic sign. 



■m 



FIG. 14. — METHOD OF PALPATING THE LOWER BORDER 

OF THE LIVER. IN THIS CASE THE LIVER WAS 

SLIGHTLY ENLARGED. 

The bladder may be felt in the hypogastrium when dis- 
tended, and in rachitic children with flabby abdomen it is 
often possible to palpate the kidneys. A rectal examination 
should be made as a supplement to the abdominal examina- 
tion in all doubtful cases. 

The thighs offer a valuable indication of the state of nutri- 
tion. If the adductor muscles are wasted, soft and flaccid to 
the touch, and the skin capable of being pinched up into 
folds, slow to disappear, we have a marked picture of wasting. 

The skin furnishes valuable diagnostic signs. The tern- 



PHYSICAL DIAGNOSIS. o3 

perature has been noted. The state of dryness or moisture is 
determined by palpation ; often an eruption can be better felt 
than seen, and the shotty feel of the skin in the early stages 
of small-pox is very characteristic. 

The tache cerebrate has been referred to. It is a hyperae- 
mic streak obtained by irritating the skin in cases of menin- 
gitis — a patch of angio-paralytic area. 

Percussion. — The usual order of examination in adults can- 
not be observed in children, as has been already pointed out. 
On account of the disturbance it is likely to produce in the 




FIG. 15. — METHOD OF PALPATING THE SPLKKX. 



child's tranquility, percussion is best left to the last in chest 
affections, just as inspection of the throat is put off until all 
other data have been obtained, when the disease points to 
that locality. 

Percussion of the head is of little value excepting for the 
purpose of eliciting tenderness, especially over the mastoid 
region, when ear disease is suspected. Macewetfs sign is a 
hollow note elicited by percussing over the anterior part of 
the skull and is indicative of distention of the lateral ventri- 
cles with fluid. It is found in meningitis and is sometimes a 
valuable early sign. 



54 DISEASES OF CHILDREN. 

In percussing the chest of the child we must bear in mind 
that owing to the lesser dimensions of the thorax and the 
greater elasticity of its walls it becomes more difficult to out- 
line the organs and to demonstrate the differences in the in- 
tensity and pitch of the percussion note at various points. 
The explanation of this phenomenon lies in the fact that the 
percussion impulse is transferred over a greater area than in 
the adult on account of the resilience of the thorax. It is, 
therefore, necessary to percuss more lightly, not only for 
fear of eliciting deep dulness from adjacent organs not 
directly under investigation, but also because it is impossible 
to outline the superficial dulness by strong percussion. This 
applies especially to the heart and thymus gland, although 
the same holds good in percussing the abdomen with the ob- 
ject of outlining the lower border of the liver or an enlarged 
spleen, etc. 

Again, it is .easier to judge between the presence or absence 
of resonance in a certain locality than to estimate differences 
in pitch and intensity. Light percussion alone makes this 
possible. 

In percussing out a superficial organ (thymus) or a super- 
ficial area of dulness of an organ situated like the heart (the 
"absolute dulness") the best results are obtained by pressing 
the middle finger of the left hand lightly against the chest 
wall and striking quick, gentle taps with the middle finger 
of the right hand. When striving to elicit deep dulness 
in order to outline a deep-seated organ like the spleen or de- 
termine the deep ("relative") dulness of the heart or liver, 
the finger must be pressed more firmly against the chest and 
the percussion strokes dealt more strongly, avoiding, loud per- 
cussion, however, which drowns out the finer shades of dis- 
tinction between the notes and practically abolishes all border 
lines. In percussing, the examiner's finger also experiences 
varying degrees of resistance, which is a great aid in locating 
the boundaries sought for and in recognizing the physical na- 
ture of pathological processes capable of impairing resonance. 



PHYSICAL DIAGNOSIS. 55 

The elicitation of deep dulness is handicapped by certain 
sources of error, and the results are often misleading. In the 
first place, there is greater likelihood of our percussion strokes 
not being of uniform force, and it is difficult to determine just 
how energetic they should be in order to outline the extent of 
space through which an organ can diminish the normal reso- 
nance of the thorax. Secondly, the area obtained may exceed 
in size the actual size of the organ under examination. This 
is especially so with the heart, as Sahli has demonstrated {Die 
Topograph! sche Percussion im Kindesalter, Bern, 1882). 

The factors influencing the percussion note over the lungs, 
independent of the adjacent organs, are, according to Sahli : 

(a.) The thickness of the thoracic wall. It is an estab- 
lished fact that the percussion note obtained over the lungs 
under equally strong percussion is the more intense the 
thinner the wall is that covers the area percussed. 

(b.) The configuration of the thorax plays an important 
role in the difference in the intensity of the resonance in dif- 
ferent localities Convexity of the thoracic wall tends to 
diminish the intensity of the percussion note, as a greater 
part of the percussion impulse is required to depress the con- 
vex wall sufficiently against the underlying structures to set 
them into vibration than is the case with a plane or concave 
thoracic wall. For this reason the flattened areas of a rachitic 
thorax give an apparent hyper-resonance when compared with 
areas of normal configuration. This modifying factor must 
also be borne in mind when percussing chests deformed by 
scoliosis and kyphosis. 

(c.) The close appositi6n of the ribs in a certain region will 
give rise to dulness at that point. This is often seen in cases 
of pleurisy before exudation has set in, and may give rise to a 
diagnostic error. The explanation of the displacement of the 
normal relationship between the ribs is a voluntary scoliosis 
from fixation excited by the pain in the affected side 
(Werner). 

(a 7 .) The percussion note obtained in an intercostal space is 



56 



DISEASES OF CHILDREN. 



of greater intensity than that obtained over a rib. This is of 
practical importance in outlining the heart, as apparent dul- 
ness beginning at the second rib may be due to the rib and 
not to the underlying upper border of the heart, as percussion 
in the second intercostal space will prove. 




FIG. l6. — DIAGRAM SHOWING LOWER BORDER OF THE 
EUNGS AND EIVER. (SAHEI.) 

Normally, the percussion note gradually increases in inten- 
sity both anteriorly and posteriorly as we descend, and then 
gradually diminishes as the lower border of the thorax is 
reached. The increase in intensity in percussing downwards 
results from greater thinness of the thoracic w r all — the pectoral 
muscles and the scapula and its muscles padding the upper 
part of the thorax considerably — and the flatter configuration 
of the chest at its mid-portion. As we descend we impinge 



PHYSICAL DIAGNOSIS. 57 

upon the deep dulness of the liver and spleen posteriorly and 
the liver and heart anteriorly. 

The lower boi'der of the lungs in the dorsal position is iden- 
tical in children and adults, and not higher as Weil claimed 
^Sahli). The following points reach the extreme lower 
border of the lungs : Right mammary line, upper border of 
sixth rib ; left mid-axillary line, upper border of ninth rib ; 



FIG. 17. — DIAGRAM SHOWING SUPERFICIAL AND DEEP 

CARDIAC DULNESS. (SAHLI.) 

posteriorly, on either side of the spine, eleventh dorsal 
spine, (Fig. 16). 

The percussion note over the sternum is more intense than 

in the adult owing to the elasticity of the thorax, for which 

reason the percussion stroke is carried to a greater part of the 

lungs than merely the underlying portion. A slight shade of 

5 



58 DISEASES OF CHILDREN. 

difference naturally exists and is apparent when percussing 
from an adjacent region of the thorax toward the sternum and 
over it, but it is no more pronounced in degree than the dif- 
ference existing in the note over a rib and in an intercostal 
space. Percussion of the sternum in children, therefore, gives 
more positive results than in the adult. In percussing from 
above downwards the upper boundary of the deep cardiac 
dulness may be traced, providing we do not use too strong a 
stroke (Fig. 17). The presence of the thymus gland may 
also be demonstrated in the upper sternal region in young 
children. In the lower sternal region cardiac dulness is 
demonstrable. Jacobi recommends percussion of the sternum 
from below, the child being supported face downward, when 
any difficulty is experienced in outlining the thymus. 

Normally the child's thorax is hyper-resonant in compari- 
son with that of the adult, and owing to the pliability of the 
chest walls a cracked-pot sound can often be elicited, espe- 
cially when the child is crying. The possibility of emphy- 
sema and cavity existing must, however, not be forgotten. 

The posture during percussion is important. If the child 
does not sit perfectly erect and the spine is curved so as to bring 
the ribs closer together on one side than on the other, we will 
obtain dulness over this area. Likewise when percussing the 
back, dulness may be elicited where it should in reality not 
exist if the mother holds the child tightly against her chest 
in presenting the child's back to us for percussion. Again^ 
dulness due to a pleural effusion changes its level with a 
change in the position of the child. Crying also causes dul- 
ness in the bases posteriorly, owing to the prolonged expira- 
tory effort. 

In abdominal disease percussion is of great value. The 
abdomen may be distended either from gas, fluid, or solid 
growths, and percussion, together with the signs of fluctua- 
tion, when obtainable, will make a differential diagnosis 
possible. 

The boundaries of the liver and spleen can be percussed 
out satisfactorily with sufficient practice. 



PHYSICAL DIAGNOSIS. 



59 



Auscultation. — In auscultating the chest of a young child 
it is most advantageous that it be held by the mother as 
shown in Fig. 18 with its back exposed to the examiner. 
This is the position in which the back and lateral regions 
also can be most satisfactorily percussed. When we wish to 
auscultate anteriorly the child is put into the crib on its back. 



4^Wr 


f| ; 


A 

1 ■ 



FIG. [8. —METHOD OF HOLDING IX! ANT DURING 
i SCUI/TATION. 



The proper time to auscultate is when the child happens 
to be in a tranquil mood, and as a rule- it is wise to begin the 
examination with auscultation. Should it then begin to cry, 
we make use of the crying sounds to determine the vocal 
resonance and the presence or absence of bronchophony. 



60 



DISEASES OF CHILDREN. 







Older children may be engaged in conversation when we 
wish to study the voice sounds. 

There are two methods of auscultation, namely, the imme- 
diate and the mediate. In immediate auscultation the ear is 
placed directly upon the chest — it being preferable always to 
interpose a towel between the physician's ear and the patient's 
body — while in mediate auscultation the stethoscope is used 
to convey the sounds from the bare chest to the examiner's ear. 

The beginner should first master 
immediate auscultation and after he has 
learned to recognize the various sounds 
and interpret them he may avail himself 
of the comforts and advantages of the 
stethoscope. Even the skilled examiner 
finds it advantageous first to listen with 
the naked ear and then more accurately 
localize certain sounds and verify his 
findings by means of the stethoscope. 
Deep-seated lesions in the chest may be 
overlooked when the stethoscope alone is 
used, for the naked ear is able to perceive 
sounds originating at some depth below 
normal lung tissue which the stethoscope 
fails to transmit. 

The main scientific purpose of the 
stethoscope is to ascertain and isolate the 
sounds from small, circumscribed areas, 
as the chestpiece of the stethoscope does 
not conduct sounds from so wide an area as does the ear. 
There is no doubt that the monaural instrument (Fig. 19) is 
the more desirable one for this purpose, but from the stand- 
point of practicability the binaural surpasses it, especially 
when working with children. With this instrument it makes 
no difference whether the child be restless or quiet or whether 
it be too sick to be taken up and held properly — it is always 
possible to get at the chest without putting oneself into an 
uncomfortable position. 




FIG. 19. — MONAURAI, 
STETHOSCOPE. 



PHYSICAL DIAGNOSIS. 



61 



The disadvantages of the binaural stethoscope are that it 
produces extraneous noises, and while it magnifies low pitched 
sounds it does not convey certain feeble, high pitched sounds 
as clearly as the naked ear or the monaural instrument. 
With constant practice, however, 
and by checking one's findings 
by immediate auscultation when- 
ever possible, these disadvantages 
can be overcome entirely. 

Instruments for magnifying 
sounds, such as thephonendoscope 
and the Bolles' stethoscope, while 
at times convenient, are on the 
whole objectionable. True, one 
can listen through the clothes 
with them and examine a patient 
without even turning him, but 
such practice is not to be encour- 
aged. As Sahli says (Klinische 
Untersuchungs-Methoden) the dif- 
ficulty encountered in ausculta- 
tion lies not in hearing the sounds 
in the chest but in interpreting 
their meaning. 

The stethoscope shown in Fig. 
20 has two sizes of chest-pieces 
which is a feature at times most 
desirable. The thumb-piece gives 
one a good hold on the instru- 
ment without danger of touching 
the tubing and producing ex- 
traneous sounds. The ear-pieces must be adjusted to each 
individual. 

The heart can be auscultated posteriorly almost as well as 
anteriorly in infants and the murmurs of congenital heart 
disease are often better heard between the scapulae than ovei 




PIG. 20. — BINAURAL STETHO- 
SCOPE WITH LARGE AM) 
small CHEST-PIECE. 



62 DISEASES OF CHILDREN. 

the cardiac area in front. The heart should always be auscul- 
tated as a routine practice. This should be the first step, as 
crying makes it impossible to discover anything abnormal. 

Normally the first sound at the apex is the loudest sound 
of the heart. Next in intensity is the pulmonary second, and 
lastly the aortic second sound. The rhythm is trochaic 
(Hoch singer). The pulmonary second may be equal to or 
even louder than the aortic up to the time of puberty (tenth 
to twelfth year). The explanation of this difference between 
the sounds of the child's heart and that of the adult lies in 
the fact that the arterial tension is much lower — the ratio 
between the volume of the left ventricle and the aorta being 
less than in adults — while the pressure in the pulmonary 
circuit is higher. 

Auscultation is seldom of use in abdominal conditions in 
children, excepting to determine the absence of intestinal 
movements as occurs in diffuse peritonitis. 

In auscultating the lungs, crying does not interfere unless 
associated with a harsh laryngeal note. In other ways it is 
an aid in giving us a deep inspiration and an audible expira- 
tion. 

The respiration of the child is of the puerile type, character- 
ized by a harsh, sonorous inspiration somewhat bronchial in 
character. This type of breathing is encountered in the 
adult when the vesicular breathing becomes exaggerated or 
increased in intensity by extraneous causes compelling the 
lung or a part of it to assume increased activity. In this 
change both the inspiratory and expiratory factors are pro- 
portionately increased in loudness and in length, inspiration 
however being more accentuated than expiration (Tyson). 
In the infant, owing to the slight movements of the chest 
wall and the purely abdominal mode of breathing, the re- 
spiratory sounds are feeble. 

As the right bronchus is of larger calibre than the left, the 
respiratory note is more intense on the right side. Bronchial 
breathing may be heard to the right of the spine in the scap- 



PHYSICAL DIAGNOSIS. 



63 



ular region, or to be more exact, broncho-vesicular breathing 
(Fig. 21). If the diaphragm be forced up by gaseous disten- 
tion of the abdomen the vesicular murmur will be suppressed 
at the bases of the lungs. 

Occasionally during deep inspiration, especially during cry- 
ing, sub-crepitant rales may be heard at the apices (supra- 
clavicular region) and at the bases posteriorly. In pneumonic 




FIG. 21. — CHILD SIX YEARS OLD; LINKS SHOWING EXTREME 

PERCUSSION BORDER OF LUNGS AND TXTKRLOBULA R 

FISSURES. BRONCHIAL BREATHING HEARD 

AT (O). 



conditions we must be on our guard not to confound the 
harsh, rasping sub-crcpitaut rales, characteristic in children, 
with pleuritic friction sounds and diagnose pleurisy where it 
does not exist. 

Pulse, Temperature, Respiration. — As in adults, the pulse 
is best felt at the wrist in children, although it can at times 
be estimated with advantage through the anterior fontanelle. 



64 DISEASES OF CHILDREN. 

The pulse is very rapid in infants, gradually decreasing in 
frequency during childhood, attaining the average rate of 76 
in males and 80 in females by the time of puberty. In young 
children the rhythm is variable and irregular, owing to the in- 
complete development of the physiological inhibitory centres. 
The pulse-rate is often affected by physiological influences to 
such an extent that it cannot be taken as a safe criterion of 




FIG. 22. — ANTERIOR VIEW OF CHILD SHOWN IN FIG. 21. 

APEX RESONANCE, DEEP CARDIAC DULNESS AND 

LOWER BORDER OF LUNGS OUTLINED. 

fever, which can only be surely determined by palpation and 
thermometry. 

During the first weeks of life the pulse-rate varies between 
125 and 150 beats per minute ; more rapid in female infants, 
as a rule, and not influenced by posture. 

From the sixth to the twelfth month it is usually 105 to 
115, and more susceptible to bodily exercise. 



PHYSICAL DIAGNOSIS. 65 

From the second to the sixth year it may be said to vary 
within 90 to 105 beats ; seventh to tenth year 80 to 90 beats, 
after which it gradually attains the average adult standard. 

The strength of the pulse is our guide in judging of the 
heart's condition, and must be carefully observed during the 
course of the acute infectious fevers and in pulmonary in- 
flammations. 

One of the most satisfactory results to be obtained in study- 
ing the pulse is when we compare it with the temperature 
and respiratory ratio. Thus in the beginning of typhoid fever 
the temperature may have risen several degrees above normal 
while the pulse-rate is still unaffected. Later it may rise 
entirely out of proportion to the temperature. The pulse 
does not, therefore, rise in a uniform ratio with the rise of 
temperature in all cases, although as a rule one degree of 
fever-heat is usually accompanied by an increase of eight 
pulse-beats. 

" A pulse-rate rather slow in proportion to the temperature 
is favorable, indicating a tranquil nervous system. A low 
pulse with high temperature invites us to look for spinal 
cause, as pressure on the brain or depressing action of drugs. 
A low temperature and frequent pulse points to local com- 
plications in the thorax or pelvis (Wunderlich). 

" A slowness in the pulse has often a great significance in 
the diagnosis of cerebral affections, and especially meningitis " 
(Finlayson). 

Irregularity in the pulse is also found in meningitis, com- 
bined with slowness. When the pulse is more rapid, the 
fever prominent and the breathing embarrassed, we should 
suspect peri- or endocarditis. 

" The number of respirations per minute does not corre- 
spond so closely to the temperature as the frequency of the 
pulse. In collapse there is often (not always) a frequency of 
respiration, and in slight fever of childhood also ; in moder- 
ate fever the respirations amount to 20 or so per minute ; in 
children to 40 or 50. In considerable or extreme degrees of 



66 DISEASES OF CHILDREN. 

fever they are higher yet, 60 in many cases ; movement also 
increases their frequency." In pneumonia and congestion of 
the lungs the rate of respiration is entirely out of proportion 
to the fever and pulse, and greatly quickened respirations 
should at once lead us to examine the chest. 

The temperature is best taken by inserting a clinical ther- 
mometer, lubricated with vaselin, into the rectum. It is 
usually a trifle higher than in the mouth, but it is much more 
satisfactorily taken here, and far more accurately than in the 
axilla or groin. The diurnal variation in the temperature is 
more pronounced than in adults, varying within a range of 
from two to three degrees. The lowest temperature is at- 
tained shortly after midnight, when it may be as low as 97 ° 
F. in the rectum, rising to a height of ioo° F. in the after- 
noon, in some instances. 

The Urine. — The difficulty of obtaining a specimen of urine 
for chemical examination, and of estimating the total quantity 
in twenty -four hours, leaves the clinical study of urine in in- 
fancy and childhood a much-neglected branch. Fortunately 
the necessity for studying the urine does not arise as frequently 
in children as in adults, but when presenting itself it is of the 
highest importance that we should know how to proceed. For 
ordinary purposes a clean sponge can be placed over the gen- 
itals and held in place by the diaper, which should have a 
layer of oiled silk or other impervious material on its inner 
surface. When the child has micturated, the urine is squeezed 
from the sponge into a clean vessel. By measuring the quan- 
tity thus obtained and noting the number of urinations in 
twenty-four hours we can quite accurately estimate the total 
quantity. Often the variations in the frequency of urination 
are a safe enough guide in estimating the functions of the 
kidneys. Should the quantity obtained by the method de- 
tailed above not be sufficient for a chemical examination, the 
process can be repeated until enough is obtained. Instances 
may arise where resort to the catheter will become necessary, 
in which case a sterilized No. 5 to 6 soft-rubber catheter is to 



PHYSICAL DIAGNOSIS. 67 

be employed. The urine can sometimes be forced from the 
bladder by gentle stroking in the suprapubic region, it being 
received into a beaker glass held under the penis. Simply 
irritating the prepuce will often excite urination. 

The daily quantity of urine gradually increases from an 
ounce at birth to six to ten ounces by the end of the second 
week. The amount is relatively large during early infancy, 
increasing from six to twelve ounces at the first month to six- 
teen ounces at the sixth month. By the second year it may 
reach twenty ounces, and by the eighth year two pints and 
over. The specific gravity is relatively low r during infancy, 
the percentage of solids being far below that of adolescence, 
but the amount of urine passed is greater in comparison w T ith 
the body-weight than in adults. The frequency of urination 
gradually decreases as the child develops and gains more con- 
trol over the sphincter vesicae ; the act is involuntary until 
after the second year. 

The variability of the character of the urine in childhood 
is w r ell known. At times it will be high-colored, staining the 
napkin, and causing the child to cry while urinating, on ac- 
count of the presence of urates and uric acid ; again, it may 
be turbid from mucus or phosphates, especially the latter in 
intestinal indigestion. The odor is in many cases quite pro- 
nounced, from the presence of aromatic compounds. 

Albumin should immediately be suspected when the urine 
imparts a slight amount of stiffness to the diaper on drying; 
in fact, it may be so abundant as to stiffen the cloth like 
starch. It is normally found in the urine of the newborn. 
Blood is most likely to originate in the kidneys in childhood, 
especially in scarlatinal nephritis, and give the urine a smoky 
appearance. Haematuria in infancy is most frequently a sign 
of scurvy. Sugar is often present in the urine of infants with- 
out any special reason to account for it; it is probably derived 
from the lactose in the milk, especially when there is a greater 
consumption than can be assimilated. 

The presence of urates and uric acid lias 'been referred to. 



68 DISEASES OF CHILDREN. 

It is usually indicative of a gouty diathesis, especially when 
the parents present such a history. 

Indican is often found in the urine of children, probably as 
a result of intestinal putrefaction (small intestine). Its fre- 
quent association with epilepsy is its most important feature. 
The majority of specimens of urine from artificially-fed in- 
fants that I have examined contained this substance in excess. 
Correctly speaking, it is an indoxyl-potassium-sulphate. 



CHAPTER III. 



THERAPEUTICS. 



In the treatment of the sick a drug should never be given, 
unless specific indications for its use exist. Even under these 
conditions medicines should not be prescribed until every 
detail of hygiene and diet has been attended to. Moreover, if 
it is possible to obtain a therapeutic result by means of such 
simple non-medicinal measures as hydrotherapy, massage and 
exercise, it is not only superfluous but irrational to subject 
the system to drug effects. The physician who prescribes 
small doses cannot shield himself from this criticism by retort- 
ing that the drug will not injure the patient and, therefore, 
it will make no difference. 

Rational therapeutics presupposes accuracy in diagnosis. 
Our drug pathogenesy, i. e., the reliable symptoms of our 
Materia Medica, is based on the pathological conditions and 
physiological disturbances induced in the healthy human or- 
ganism by the administration of the drug in sufficient quan- 
tity to induce these phenomena. Our method of prescribing 
is based on the rule that a drug capable of producing certain 
pathological effects, with the consequent appearance of cer- 
tain symptoms arising therefrom, is capable of controlling 
and removing identical symptoms when encountered in a 
sick individual. Our dosage is based on the observation that 
while large doses aggravate these symptoms, smaller ones 
act curatively. 

This mode of practice, however, like every other therapeutic 
system, has its limitations. Circumstances arise, as Hahnemann 
himself points out {Organon of Medicine, % 67), "where dan- 
ger to life and imminent death allow no time for the action 
of a homoeopathic remedy." It is largely a matter of opinion 
as to just what constitute the indications for physiological 



70 DISEASES OF CHILDREN. 

interference. Errors are made on both sides. The early re- 
sort to powerful stimulants in all fevers and the free use of 
the depressing "antipyretics" has undoubtedly done more 
harm than the absolute neglect of taking the state of the 
heart and the height of the fever into consideration and rely- 
ing exclusively upon the "indicated remedy." 

"In order to obtain indications for treatment, make a diag- 
nosis. The art is becoming both more accessible and, through 
honest and hard work, more easy with the aid of modern 
methods (Jacobi)." By "diagnosis" is not meant the mere 
tagging of a name to a disease — anaemia, jaundice, dropsy, 
even more exact nomenclature, such as lobar pneumonia and 
typhoid fever, is not a diagnosis. Recognize the patient's 
vital resistance, the state of his heart muscle. Will it see 
him through unaided? Is your remedy sustaining it or will 
you have to resort to more energetic means? Is it possible to 
keep up nutrition by the ordinary means? Can we foretell 
and prevent complications? This is diagnosis in the modern 
sense of the term, and when Gerhardt says "without diagnosis 
no intelligent therapy," he does not refer to the mere detection 
of physical signs of disease. 

Stimulants. — In a previous chapter (page 18) it has been 
pointed out that cold water is a powerful stimulant under cer- 
tain conditions. This method of stimulation is, however, not 
always available or applicable. 

Alcohol is well borne by young children and is one of the 
most generally used stimulants we possess. Aside from its 
sustaining action upon the heart it is a food in the sense that 
it is oxidized in the body and thus spares tissue waste. Alco- 
hol does not materially affect the blood pressure and is, there- 
fore, not to be relied upon in a rapidly failing heart or in col- 
lapse. Its use is rather to ward off such an emergency than 
to meet it. The antidotal action of alcohol in the various 
toxaemias is one of its most valuable attributes ; this applies 
especially to septic conditions and low typhoid states. In 
diseases of short duration, however, with high fever, it is sel- 



THERAPEUTICS. 71 

dom indicated ; in fact, it is useful only when such cases 
become adynamic. In gastro-intestinal affections and even in 
nephritis it is not contra-indicated providing it be cautiously 
administered and well diluted. 

The indications for the use of alcohol in a continued fever 
are a soft, rapid pulse and a failing of the muscular element 
in the first sound of the heart. The appearance of restless- 
ness and delirium, dry tongue, distended abdomen and pul- 
monary congestion calls for an increase in the dose. In diph- 
theria, alcohol may safelv be used from the very beodnnino- in 
moderate dosage, and increased as the necessity arises. 

In a young infant, ten to twenty drops of brandy well 
diluted, may be given every two to three hours when urgently 
required. An infant one year old may take half a drachm 
every two hours; this can be increased to one drachm, if 
necessary. A child from three to five years old may take as 
high as two drachms every two hours in low typhoid condi- 
tions. When the odor of alcohol can be detected on the breath 
we may know that the patient is fully under its influence and 
repetition of the dose becomes unnecessary. 

Camphor. — As a quick, diffusible stimulant there is nothing 
better than Camphor when urgent symptoms are to be met. 
The picture calling for Camphor is one of collapse. Drop 
doses of the tincture should be used, or what is better, cam- 
phorated oil injected subcutaneously. Personally, I prefer the 
neutral solution of Camphor. This is of the same strength 
as the oil, namely, 12^ per cent. In a young infant two to 
three minims suffice. A year-old babe may receive five 
minims, while a child from three to five years can safelv be 
given ten to fifteen minims. If no result is seen within 
fifteen minutes, the injection may be repeated in a somewhat 
smaller dose. 

Digitalin, Strychnia. — Cook (. Itnerican Jour. Med. Scii net s, 
April, 1903) has demonstrated by means of observations with 
the sphygmomanometer of Riva-Rocci that Digital in will 
raise the blood pressure in cases of failing circulation within 



72 DISEASES OF CHILDREN. 

fifteen minutes, and maintain it at a safe point for several 
hours. It is, therefore, to be preferred to Strychnia when 
prompt results are demanded. Strychnia, on the other hand, 
maintains the pressure longer and better than Digitalin and 
should be used to reinforce the latter when heart failure is to 
be averted. 

Cook's experiments have also demonstrated that the blood 
pressure is a most valuable guide in showing us when stimu- 
lation is actually necessary. Some cases that appeared to 
require it were found to have almost normal pressure and 
consequently the stimulant was stopped, while others that did 
not betray their critical condition by the ordinary signs were 
found dangerously near the point at which life ceases. The 
dosage of these drugs is one four-hundredth grain hypo- 
derm ically in a young infant, and one two-hundredth grain in 
a child. 

Prescribing. — The method of prescribing for children re- 
sembles the method of diagnosing their ailments in that we 
are dependent entirely upon objective signs for reliable indica- 
tions for a remedy. Far from being a disadvantage, this really 
gives us a better opportunity for practicing scientific thera- 
peutics because the source of error resulting from the unreli- 
ability of "subjective sensations" is removed. Moreover, the 
data upon which we prescribe are based on pathological states 
which we interpret as "objective symptoms," and. therefore, 
more demonstrable and tangible than the other class of indi- 
cations. 

Prescribing is practically diagnosing the remedy, and we 
should go about it in much the same manner. The family 
history, the constitution and temperament, previous history, 
mode of onset, etc., all offer clues to the proper remedy. 
While the diathesis and temperament cannot be accepted as 
genuine indications for a remedy, still we know that certain 
individuals are especially susceptible to certain drugs, that 
the state of their nutrition calls for certain remedial agents, 
and that distinct moods and peculiar states of the mind and 
nervous system come within the sphere of drug action. 



THERAPEUTICS. 73 

Each diathesis has a group of remedies wonderfully adapted 
to its needs ; the temperaments are well defined in our Materia 
Medica, and the constitution likewise, whenever it presents 
special susceptibility to a drug. This has been noted under 
the clinical indications of our symptomatology. 

The previous history often points to a constitutional rem- 
edy ; thus, late appearance of the teeth and a late closure of 
the fontanel will suggest the need for Calc. phos.; the oppo- 
site condition will rather point to Calc. carb. Former skin 
eruptions, especially when combined with snuffles and sore 
mouth, will probably indicate one of the Mercuries\ or if the 
child comes to us with a history of having been salivated, 
Hepar, Nitric acid and the Iodide of potash will suggest 
themselves. Certain remedies we know to be especially 
useful in removing the remote effects of various ailments ; 
thus, Sulphur after pneumonia ; Arnica when there has been 
a trauma ; Silicea sometimes after vaccination and Ignatia 
after fright. Again, disturbances resulting from the abuse of 
such drugs as Iron and Quinine often require Pulsatilla ; 
after anodynes, purgatives, cough mixtures and the like Nux 
vomica will prove useful. 

We should observe the position assumed by the child dur- 
ing sleep and waking. This often offers valuable suggestions 
for a remedy. For example, lying quietly upon the affected 
side is a characteristic indication for Bryonia. 

The condition of the skin, whether dry or moist, hot or 
cold, red or cyanotic ; also, if eruptions be present, their char- 
acteristic features — all are important to the prescriber. 

The physiognomy may offer suggestions ; the knitting of 
the brow r pointing to headache, the fanlike motion of the alse 
nasi, indicating dyspnoea. 

The character of the cry may indicate Apts, when there is 
effusion into the brain ; it may point to Be//., Aeon, or Puis, if 
otitis is diagnosed, or Mercury and Ka/i bichromicum when 
syphilis is suspected from the hoarse, feeble tone. Sudden 
hoarseness should, however, lead us to suspect the advent of 
6 



74 DISEASES OF CHILDREN. 

croup, when we naturally choose between Aconite, Spongia 
and Hepar. 

In examining the chest we aim to define the character of 
the rales present, and are thereby able to differentiate reme- 
dies. Thus, Ant. tart, and Ipecac, are differentiated by the 
predominance of and finer character of the rales in the latter ; 
in Ant. tart, there are coarse rales, in the larger bronchial tubes 
from the accumulation of mucus which the patient is unable 
to cough up. The discovery of consolidation, effusion and 
friction sounds will also aid us in prescribing. 

Objective signs in cardiac disease are valuable aids in pre- 
scribing, only to mention Aeon, and Rhus tox in hypertrophy ; 
Spigelia and Bryonia in endocarditis; Glonoin for the high 
arterial tension and Cactus in valvular affections. 

In prescribing for diseases of the nervous system we must 
carefully differentiate the various conditions occurring here. 
Thus, in differentiating cerebral anaemia and hyperemia from 
inflammatory processes our prescribing will necessarily be 
more accurate and successful. 

After we have decided that the meninges are involved, a 
number of well-known remedies will immediately present them- 
selves. To differentiate between them we must take into 
consideration the degree of fever and cerebral congestion ; 
the presence or absence of convulsions, photophobia and stra- 
bismus ; the psychical state, manifested by the disposition, 
character of sleep and state of consciousness; delirium or 
coma. This, together with a general survey of the patient, 
gives the data for finding the similimum. 

And so the special senses, the alimentary tract and the 
genito-urinary tract are all to be carefully studied in the man- 
ner above detailed, in order to gain the requisite knowledge 
for making a prescription. The results of such prescribing 
bring their due reward ; it is time well spent in fruitful labor. 

Dosage. — The dose, while an important question, is not the 
principle upon which Homoeopathy is based. Our unfair 
critics would have it believed that Homoeopathy and micro- 



THERAPEUTICS. 75 

therapy are one and the same thing. The fundamental principle 
of Homoeopathy, however, is the sound deduction formulated 
by Hahnemann as the general therapeutic rule of practice, 
similia similibiis curentur, and the dose recommended was 
the smallest one that would act curatively without aggravat- 
ing the condition for which it was prescribed. Theie is no 
necessity, therefore, for invading the realm of the infinitesimal 
in order to practice Homoeopathy. In fact this method of 
dosage was adopted by Hahnemann himself only in his later 
years. 

To the beginner, and especially to those not in sympathy 
with the theory of attenuation, small doses of the tincture 
and the lower dilutions are to be recommended. When 
employing insoluble substances, the lower triturations may 
be used. Let the dose just fall short of producing medicinal 
aggravation, and if the remedy be homceopathically indi- 
cated, a curative result will follow. Accordingly, the liquid 
remedies, excepting the very poisonous ones, may be adminis- 
tered in doses of one to two drops of the first or second decimal 
dilution, repeated every one to two hours in acute conditions, 
without fear of doing any harm. In young infants the second 
and third decimal dilutions are usually preferable. The same 
may be said of triturations ; but it is reasonable to suppose that 
insoluble and apparently inert substances like Silica and the 
Carbonate of Lime are more active when their molecules are 
mechanically separated than in the crude state. The inter- 
esting and convincing experiments conducted by Dr. Percy 
Wilde, published in the Journal of the British Homoeopathic 
Medical Society, January, 1902 ("Energy in its Relation 
to Drug Action "), prove conclusively that the process of 
trituration induces decided changes in the physical properties 
of the substance thus treated. There seems to be no doubt 
that this process converts apparently inert substances into a 
state in which they can enter into chemical combination with 
certain cells of the human economy for which they possess a 
selective affinity. If, therefore, we desire to obtain the thera- 



76 DISEASES OF CHILDREN. 

peutic action of one of these remedies, we must give it in a 
finely subdivided state, such as the third to sixth decimal 
triturations represent. On the other hand, when we desire to 
obtain simply the nutritive or chemical effect, as in using 
Iron in anaemia, a much larger dose becomes necessary. The 
action of Ferrum phosphoricum in the third decimal tritura- 
tion in acute bronchitis is essentially different from the action 
of Ferrum reductum crude or in the first decimal trituration 
in anaemia ; in the former the action is medicinal, while in 
the latter it is chemical. 

Triturations are usually dispensed in tablet form, each tablet 
representing one grain of the triturate. In acute conditions, 
a tablet may be administered every one to two hours ; in 
chronic affections, two tablets four times daily is the usual 
dose. Naturally, such poisonous substances as Bichloride of 
Mercury, Cyanide of Mercury and Arsenious acid must be 
given with caution when used in the third decimal trituration. 



CHAPTER IV. 

INFANT FEEDING. 

A comparison of the results obtained by artificial feeding 
and breast feeding indicates conclusively that, as ordinarily 
practiced, the artificial method fails to supplant successfully 
nature's method. 

The question naturally arises, can a child be weaned with 
any degree of safety before the usual time, and can those who 
are deprived of breast milk from the very beginning of their 
existence be spared the gastro-intestinal derangements and 
the later constitutional manifestations of faulty nutrition 
which are almost universally the lot of hand-fed children? 

A close study of the subject of infant feeding reveals the 
fact that nature can be imitated so closely by carefully and 
intelligently conducted methods that but very slight, if any, 
difference in results should occur. In the first place, we 
must study the chemical composition of human milk, and 
furnish the child with a substitute having a similar composi- 
tion. Secondly, the food must be served perfectly sterile and 
of the temperature of breast milk, as the latter is entirely 
free from pathogenic and fermentative micro-organisms 
when secreted from a healthy breast, beside being of the body 
temperature. Thirdly, the proper quantity must be admin- 
istered, and at regular and suitable intervals. If these con- 
ditions are carried out, artificial feeding is robbed of its ter- 
rors, and becomes a boon to infants and to sickly and delicate 
mothers who are not able to stand the drain of nursing. 

HUMAN MILK STUDIED IN COMPARISON WITH OTHER MILKS 
AND FEEDING MIXTURES. 

Human milk is an alkaline fluid, bluish-white in color, of 
watery consistency and sweetish taste. It contains a slightly 



78 DISEASES OF CHILDREN. 

lower percentage of total solids than cow's milk, and consid- 
erably less proteids, but a higher percentage of lactose (sugar 
of milk). This accounts for the difference in appearance and 
taste. The amount of fat is about equal in both, unless we 
take into consideration the milk of special breeds of cows, 
such as the Jersey, in which the fat may be as high as 5 per 
cent., more than 1 per cent, above average human milk. 

The distinctive feature of human milk is its apparent low 
percentage of proteid, as compared with other milks. The 
amount of this nitrogenous element ranges between 1 and 
2 per cent., the average obtained by Cautley from a large 
number of analyses being 1.93 per cent. Cow's milk con- 
tains almost uniformly 4 per cent, of proteid. In good dairy 
milk, where we obtain a mixed product from many cows, 
it seldom varies from this standard, and it can be kept so by 
the proper feeding and management of the herd. Mother's 
milk presents a much greater fluctuation, owing to the highly 
susceptible nervous system of the human subject. 

There is, however, a difference in the proteid, aside from 
percentage, for the proteid of human as well as of cow's milk 
is not a single body, but can be resolved into caseinogen and 
lact-albumin, two bodies of totally different character and 
composition. In cow's milk the proportion of caseinogen to 
lact-albumin is four to one ; in human milk, two to one. — 
(Kcenig.) 

The caseinogen of cow's milk is precipitated by acetic acid 
or by a saturated solution of magnesium sulphate. The lact- 
albumin is not affected by these reagents, but precipitates 
with tannic acid and by boiling. It is the chief constituent 
of the scum which forms on boiled milk. To estimate the 
percentage of lact-albumin in a given specimen of milk it is 
first necessary to precipitate the caseinogen with acetic acid, 
filter, and in the filtrate the lact-albumin can be estimated by 
tannic acid. 

The caseinogen found in human milk forms a much finer 
curd than that of cow's milk when coagulated with the rennin 



HUMAN MILK. 79 

of the gastric juice. Again, the greater proportion of caseinogen 
to lact-albumin in cow's milk is another factor making it less 
digestible and less suitable for the infant. 

Ass's milk more closely resembles human milk in the 
amount of proteids present, containing according to an 
analysis by Dujardin-Beaumetz, 1.23 per cent, proteids, 6.93 
per cent, lactose, and 3.01 per cent. fat. The objection to 
its use is the difficulty of obtaining it and the low proportion 
of fat present. 

The fat-globules of human milk are smaller than those of 
cow's milk, but aside from this there is no material difference 
in the cream of the two. 

The reaction of human milk is alkaline, while cow's milk 
is usually acid by the time it reaches the consumer. This 
acidity is often a source of considerable disturbance in the 
child's digestion, but the difficulty is controllable, as it is a 
simple matter to recognize this condition of the milk and 
correct it. 

The following table presents a comparison of human and 
cow's milk, constructed from the average of a large number 
of analyses by competent chemists. 

Standard Comparative Table of Human and Coze s Milk 
(Cautley, "The Feeding of Infants.") 

Cow's Milk. Human Milk. 

Water. 87. 87.46 

Solid- 13. 12.54 

Proteids, 4.06 1.95 

Fat, . . 3.70 3.62 

Lactose, . 4-4S 6.75 

Salts, 0.76 o.2t> 

Reaction . . . Acid. Alkaline. 

A great variation is found in the results obtained by differ- 
ent observers in analyses of human milk, the fluctuations in 
the percentages of proteids and fat being very marked at times, 
even in the same subject. Rotch cites a case in which 
the proteids rose from 2.53 to 4.61 per cent, in a wet-nurse, 
from being fed on a richer diet than she had been accustomed 



80 DISEASES OF CHILDREN. 

to. Again, one observer will report having found 2 per cent, 
of proteids, while another finds 1 per cent. In a series of 
analyses made by A. V. Meigs the proteids varied from .73 
1.27 per cent.; fat from 2.4 per cent, to 9 per cent. In a 
series of careful analyses recently reported by Hofmann, of 
L/eipzig, the percentages stand as follows: Proteids, 1.03 per 
cent; fat, 4.07 per cent; lactose, 7.03 per cent.; salts, 0.21 per 
cent. 

This only demonstrates the fact that the human subject is 
a very sensitive organism, easily influenced by emotional fac- 
tors, character of diet, amount of exercise, and certain physi- 
ological states, such as the recurrence of the catamenia or 
pregnancy. 

MILK ANALYSIS. 

When an infant fails to digest breast-milk, or does not 
thrive on it, before condemning the child's digestive func- 
tions, we should examine the milk. Under all conditions, 
when the food disagrees it becomes imperative to institute a 
chemical analysis and microscopical examination of the milk. 
The information sought need be no more than an estimation 
of the fat and proteid percentages, while the microscope 
reveals the number and condition of the fat globules, whether 
perfectly or imperfectly emulsified, showing also abnormal 
elements when present, i. e., colostrum corpuscles in excess? 
pus corpuscles, micro-organisms. The physician is to be 
encouraged in making these examinations, and I can only 
repeat here what I have elsewhere pointed out {The Dietetics 
of Childhood in Health and Disease, Trans. Amer. Institute 
of Horn., 1901, p. 398), that a milk analysis is by no means 
so complicated a procedure as is generally supposed, being in 
no wise more troublesome than an ordinary examination of 
urine. 

First, we must obtain a sufficient quantity to judge of the 
appearance of the milk. If the quantity secreted by the 
breasts be insufficient for the infant's needs, the case is hope- 



MILK ANALYSIS. 



81 



less from the beginning, unless we can increase it with gal- 
actogogues. 

The specific gravity ranges from 1025 to io 35> the average 
being 1030. The reaction should be alkaline. The method 
of obtaining these data is identical with that employed in 
urinalysis, excepting that a smaller instrument for obtaining 
the specific gravity is preferable — a lactometer — (Fig. 23) 




FIG. 23.* — HOLT'S APPARATUS FOR EXAMINING WOMAN'S MILK 
CONSISTING* OF A LACTOMETER AND CRKAM GAUGES. 



owing to the smaller quantity of specimen one is obliged to 
work with. The specimen is best obtained with a breast- 
piunp, the middle portion of the milking being taken as an 
average sample. 

The percentage of fat is the most vital point in question in 
passing judgment upon a sample of milk. The cremometer- 
or cream-gauge — (Fig. 23) an instrument in which the milk 

Made by Kimer .X: Amend. New York City. 



82 DISEASES OF CHILDREN. 

is allowed to stand until the cream rises to the top, when the 
percentage can be read off — offers a simple but not very 
accurate method of obtaining the fat per cent. Five per 
cent, of cream is equivalent to 3 per cent, fat by this 
method (Holt). The separation of the cream, however, does 
not depend alone upon the amount of fat present, but is 
influenced by such physical states as the temperature, size 
of fat globules, and specific gravity of the milk (Conrad), 
making it uncertain and unreliable. 

The lactobutyrometer of Marehand gives more accurate 
results. The milk-tubes, supplied with the centrifuge, are 
constructed on a principle similar to that of Marchand's 
instrument, and offer a rapid and convenient method for 
obtaining the fat percentage. The lactobutyrometer is a 
graduated tube into which five c.cm. of milk are poured, 
together with a few drops of liquor sodcs, after which five 
c.cm. of sulphuric ether are added, and the fluids thoroughly 
intermixed by gentle agitation. Alcohol (90 per cent.) is then 
added in the same quantity — marks upon the tube indicating 
the proper amount of each element used — the tube is stop- 
pered, again shaken, and placed in warm water for half an 
hour. The fat separates into a distinct oily layer that floats 
to the top, where the percentage can be read off by the scale 
on the tube. 

The estimation of the amount of proteids is of less import- 
ance, and the data furnished by the character of the child's 
stools are usually sufficient. An approximate estimate of the 
percentage of proteids is obtained by comparing the specific 
gravity of the milk with the fat percentage. The specific 
gravity is elevated by proteids and lowered by fat. If, there- 
fore, fat be deficient and the specific gravity low, we must 
infer that the amount of proteids must also be deficient. A 
high specific gravity with normal fat would, on the other 
hand, indicate an excess of proteids. 

A microscopical examination should reveal a preponderance 
of small, uniformly-sized fat globules, indicating thorough 



MILK ANALYSIS. 83 

emulsification ; they should be present numerously in the 
microscopic field. After die third week the milk must be 
free from all cell-elements, of which the colostrum corpuscle 
is an example, being the remnant of protoplasmic bodies 
originating from the cells of the mammary gland acini. 

Cow's Milk. — A few simple facts applicable to cow's milk 
are worthy of mention, as it often becomes necessary to decide 
whether a given sample of milk is a suitable food for the 
infant. In the first place, a quart of milk standing for six 
hours after milking in an ordinary milk bottle should show a 
layer of cream in the neck of the bottle six inches deep. This 
cream contains on an average 12 per cent, of fat, but it varies 
in richness in the different layers ; the top ounce may contain 
25 per cent., and the sixth ounce only 5 per cent, fat (Fig. 
25). (Chapin.) In any quart bottle of milk en which 
cream has risen the top nine ounces will contain about three 
times as much fat as the whole milk contained, and the top 
fourteen or fifteen ounces about twice as much (Chapin). 
This fact is taken advantage of in the top-milk method of 
home-modification of milk, known as "Chapin's method," 
and to my mind, the most practical as well as accurate method 
at our command. 

Impurities. — Pathogenic bacteria gain entrance into the 
milk either with dirt acquired during milking, i. e. y stable 
filth, or direct from the milker, or through the use of impure 
water in washing out the containers. The germs that cause 
the milk to turn sour come mostly from the first few jets from 
the cow's teats. If these first jets are rejected, perfect cleanli- 
ness observed, and the milk cooled below 6o° F. immediately 
after milking, it is practically sterile, will keep satisfactorily 
and can be fed without sterilizing excepting in hot weather. 

Preservatives. — The presence of a preservative, e. g., form- 
aldehyde, should be suspected in a milk which does not 
curdle within twenty-four hours when placed in a stoppered 
bottle and kept in a warm place. 

Reaction. — The quantity of lactic acid that has Formed in 



84 DISEASES OF CHILDREN. 

the milk by the time it reaches the consumer is a good index 
of the amount of care that has been exercised in handling it. 
The sense of smell and taste is hardly accurate enough to 
afford a reliable test in determining the quality of the milk^ 
and the simplest and most practical means of deciding the fit- 
ness of a specimen of milk is offered by the "Ideal Milk 
Testers." One of these tablets is dissolved in an ounce of 
water, and the resulting pink solution is added, a teaspoonful 
at a time, to a teaspoonful of milk until the mixture becomes 
permanently decolorized. By following the scale accompany- 
ing these testers we can draw our conclusions. The reaction 
depends upon the neutralization of the lactic acid in the 
milk with Sodium bicarbonate, the indicator being phenol- 
phthalein. 

CAUSES INFLUENCING THE COMPOSITION OF 
BREAST MILK. 

The milk obtained at the beginning of a milking is known 
as the fore-milk; it is watery and poor in fat. Next comes 
the middle-milk, and lastly the strippings. The middle-milk 
should be used for an analysis when the contents of the entire 
udder or breast cannot be obtained. The strippings are espe- 
cially rich in fat, and also contain a higher percentage of pro- 
teid than the fore-milk. 

The intervals at which the breast is emptied markedly influ- 
ences the composition of the milk. The longer the interval, 
the more watery the milk, and the more frequently the breast 
is used, the more concentrated the milk becomes. When the 
bad habit of putting the child to the breast every one or one 
and a half hours is persisted in, a veritable "condensed milk" 
will eventually be secreted, which, it is needless to state, 
cannot be digested by the infant. It may be laid down as a 
maxim that the more frequently the child is nursed, the more 
indigestible the milk becomes. The over-stimulation of the 
mammary gland leads to an increased secretion of proteids, 
while the percentage of fat is also augmented, the milk re- 
sembling the strippings in this respect. 



THE COMPOSITION OF BREAST MILK. 85 

Food and exercise exert a marked influence upon the 
composition of milk. The richness of the milk, that is the 
amount of fat, is increased by a nitrogenous diet, and is de- 
creased by an excess of fatty foods, owing to the diminished 
metabolic activity induced by such a diet. 

The proteids are increased, together with the fat, on a lib- 
eral proteid diet ; also from increased frequency of nursing, 
as has been pointed out, and especially w T hen a liberal diet is 
enjoyed, together with insufficient exercise. This is fre- 
quently a source of much trouble with wet-nurses, who, en- 
tering upon their new duties with privileges not formerly 
enjoyed, a diet and sedentary occupation to which they are 
not accustomed, soon secrete a milk hardly to be distin- 
guished from rich cow's milk in its chemical composition and 
indigestible character. To correct this condition the nitrog- 
enous food must be considerably cut down and sufficient ex- 
ercise taken until the percentages become normal. 

The effect of alcohol moderately used is not injurious to 
the milk, and in some instances is highly beneficial to the 
mother. Some of the malt liquors certainly act as galacto- 
gogues, and the amount of fat is slightly increased by the 
use of alcohol. When used in excess, serious gastro-intestinal 
disturbances in the infant may arise. 

Menstruation sometimes induces changes in the milk 
which cause it to disagree. Rotch reports a case in w 7 hich 
the proteids rose to 2.12 per cent., while the fat fell to 2.02 
per cent, rendering the milk difficult of digestion and inter- 
fering with the regular rate of progress in the child's weight. 
On the other hand, Schlichter, who made analyses in thirty- 
three cases of menstruating women, concludes that diarrhoea 
and colic should rather be looked upon as coincidences, for he 
found no decided alterations in the milk. 

Should the mother become pregnant it is not advisable to 
continue breast feeding, as the drain upon her system is usu- 
ally too great to be borne by the average woman, and, besides, 
there is danger of inducing miscarriage. Moreover, the child 



86 DISEASES OF CHILDREN. 

usually ceases its progressive gain in weight, and evinces 
signs of not being satisfied with its nourishment. If it is 
necessary, however, to temporize on account of the delicate 
state of the child and the time of year, it may be suckled to 
the sixth month, and then partial weaning instituted. This 
will rarely be necessary, for with our present knowledge of 
infant feeding, and the accurate and safe methods at our dis- 
posal, the dangers of w 7 eaning, formerly so much feared, can 
be reduced to a minimum. 

The wet nurse is not ordinarily a desirable substitute for 
the mother's breast, nor is it always possible to obtain one 
that will conform to the requirements necessary in fulfilling 
such a charge. In the first place, a careful medical inspec- 
tion must be instituted in order to be certain that no evi- 
dences of constitutional or contagious disease are present. 
Secondly, there must be a sufficient quantity of milk secreted 
and the breast and nipples must be in a normal condition. It 
is also important that the stage of lactation shall correspond 
closely to the age of the infant to be nursed ; especially 
disadvantageous is it for an older infant to suckle from a 
nurse in the early period of her lactation, the converse condi- 
tion being less unfavorable. (Baginsky, Lehrbuch der Kinder- 
krankheiten.) The prominent influence of diet and exercise 
upon the composition and digestibility of the milk has been 
referred to above and the strictest regulations must be en- 
forced in this direction. Highly seasoned food is also to be 
avoided, as well as all acid fruits and salads, indigestible 
vegetables, and the free use of alcoholics. 

THE MODIFICATION OF COW'S MILK. 

It has been pointed out that cow's milk in its raw state is 
not a suitable infant food for two reasons, namely, on account 
of the excessive amount of proteids and their indigestible 
character as compared with those found in mother's milk, 
and the contamination by micro-organisms so universally 
present. To overcome the first objection, we must put the 



THE MODIFICATION OF COW'S MILK. 87 

milk through a process of modification, in which the per- 
centages of its proximate principles are made to conform to 
the standard composition of human milk. Sometimes, how- 
ever, it will be found necessary either to reduce or increase 
the percentage of these elements, the necessity and indication 
for which will be discussed, later. 

By referring to the table shown below an idea of the dif- 
ference between human and cow's milk may be obtained. Re- 
garding the percentage of proteids in human milk, no fast 
rule can be laid down, and it has been shown how analyses 
by different chemists vary, and how strongly diet, exercise 
and constitutional disturbances influence the composition of 
the mammary secretion. 

The following table represents a fair working basis for this 
problem : 

Human. Cow. 

Percent. Percent. 

Proteids, 1-2 4 

Fat, .... 4 4 

Sugar, 7 4-5 

Water, 87 86 

Reaction, Alkaline. Acid. 

Gaertner (Therapeutische Wocheuschrift, May, 1895), has 
devised a practical method of modifying cow's milk to 
approximate human milk in composition by the use of 
the centrifuge. Equal parts of distilled water and milk 
are put into the centrifuge and separated into two portions, 
one containing all the cream, beside 2 per cent, of casein. 
A tablespoonful of sugar of milk is added to each half litre 
of this " Fettmilch," which renders it very similar in compo- 
sition to human milk and a very useful food for most infants. 
Fischer (Medical Record, Dec. 11, 1897) has recently reported 
a series of cases, among them entero-colitis, gastroenteric 
catarrh and athrepsia, which improved rapidly under a change 
of diet to this formula. A preparation very similar to this 
can be made at home simply by allowing the milk to sepa- 



88 DISEASES OF CHILDREN. 

rate by standing, this method having long been in use, and 
already warmly recommended by Guernsey {Obstetrics, p. 622; 
Phila., 1867). 

It is, however, often not only desirable, but absolutely 
necessary to vary the percentages of the proximate princi- 
ples, or to imitate closely a given formula, in which case we 
must have a definite mode of procedure, which is at the same 
time simple and practical in its application. A method of 
modifying cow's milk to conform with the indications of 
each case, which I have used with signal success both in 
private practice and in my hospital work, has been reported 
on a former occasion, under the title The Artificial Feeding 
of Infants with Synthetical Milk {Hahnemannian Monthly, 
Feb. 1898). It is, however, too complicated for use in private 
practice, and the methods of obtaining varying percentages 
of fat and proteids detailed below will answer for all ordinary 
purposes. 

A word as to the use of milk sugar and cane sugar. It is 
held that lactose, being the natural sugar found in milk, and 
being more assimilable and less liable to undergo fermenta- 
tion than cane sugar, should always be used in artificial 
foods. The objections to cane sugar are, how T ever, rather 
theoretical than practical, and we know from the condensed- 
milk baby that cane sugar has great fattening properties. 
Besides, it does not readily undergo fermentation, its use as a 
preservative demonstrating this fact. Again, lactose, on ac- 
count of its property of being converted into lactic acid, 
which again may be converted into butyric acid, is often ob- 
jectionable. It may also act as a laxative. Jacobi {Archives 
of Pediatrics, Oct., 1901) opposes the use of milk sugar on 
these grounds and also because it is difficult to obtain a pure 
article. He doubts the identity of the sugar of milk from the 
cow with that of human milk and calls attention to the danger 
resulting from the presence of lactic acid in the alimentary 
tract. This acid throws out of solution the casein of the milk 
and causes diarrhoea. It also increases the elimination of 



THE MODIFICATION OF COW'S MILK. 89 

lime-salts from the tissues by the kidneys and lays the founda- 
tion for the development of rickets and malnutrition. 

In many of the larger cities milk laboratories have been 
established, where the physician may have made up and 
served a formula of any proportion of fat, proteids and sugar 
that he wishes to prescribe. These laboratories are a great 
convenience, and they are conducted on the lines laid down 
by Rotch, who was the first to advocate mathematically ac- 
curate percentage feeding. But the results of prolonged feed- 
ing with laboratory milk are as a rule unsatisfactory. Pro- 
teid digestion is defective and the fat does not seem to be 
assimilated. Evidences of mal-assimilation and malnutrition 
are commonly observed and I have seen rickets develop under 
these circumstances. Starr {Diseases of the Digestive Organs 
in Children) speaks with disapproval of the use of laboratory 
milk. He has observed the development of gastro-intestinal 
catarrh in many instances and even of scurvy. In his 
opinion it is the complete separation of the fat and proteids 
in the preparation of the milk formulae that interferes with 
the emulsification and digestibility of the fat. Holt, on the 
contrary, does not believe that this is of any practical im- 
portance and speaks favorably of laboratory milk. 

The theory upon which this mode of feeding is based is 
correct, but personally I prefer the home modification of milk. 
There is no doubt that the results obtained from feeding a 
properly diluted top-milk — whose fat percentage can be easily 
gauged — are far superior to those obtained from the use of a 
modified milk consisting of a readmixture of the milk 
elements after mechanical separation, that have again sepa- 
rated because the food must be prepared in the laboratory 
anywhere from twelve to twenty-four hours before the last 
bottle is fed to the child, and that must be rigorously steril- 
ized, or be sour and unfit for use by the time the child is 
ready to take it. It is very likely that the success of laboratory 
milk has depended more upon the purity of the article than 
upon the strict adjustment of percentages. 
7 



90 



DISEASES OF CHILDREN. 



The following rule for diluting cow's milk expresses the 
underlying principle of the home modification of milk : For 
an infant under two weeks it should be diluted five times ; 
from two weeks to six weeks, four times ; from six weeks to 
three months, three times ; from three months to four months, 
twice ; and from four months to nine months, once. 

If, however, we were to use ordinary milk, the result 
would be a deficiency of fat and lactose in the food, for which 
reason a milk containing 10 per cent, fat (a 10 per cent. 
" top-milk ") must be employed up to the third or fourth 




FIG. 24. — DIAGRAM SHOWING THE PERCENTAGE OF FAT IN WHOLE 
MILK AND IN THE UPPER LAYERS OF SET MILK USED IN- 
MODIFYING MILK. (AFTER HOLT.) 

month and a 7 per cent, top-milk from the fourth to the 
ninth month. After that, ordinary milk, slightly diluted, 
may be administered (Fig. 24). 

The water used as a diluent must contain milk-sugar in 
the proportion of one ounce to every twenty ounces of food 
and about the same proportion of lime-water to neutralize the 
acidity of the milk. In the later period of infancy granu- 
lated sugar may be used instead of milk sugar. About one- 
third less than the amount of milk sugar specified should be 
added. It is always best to boil the water for ten minutes 



THE MODIFICATION OF COW'S MILK. 



91 



and dissolve the sugar therein while still hot. Lime-water, 
however, is decomposed by high temperature. 

Ten per cent, milk is obtained by dipping off the upper ten 
ounces from a quart bottle of milk that has stood on ice for 
from four to six hours (until all the fat has risen to the top) 



F0R16 0Z. 

TOP MILK 

REMOVE 

THIS 

QUANTITY 
AND MIX 




FOR 9 OZ, 

TOP MILK 

?- REMOVE 

THIS 

QUANTITY 

AND MIX 





FOR REMOVING 

TOP MILK 
1ST OZ. MUST 
BE REMOVED 

WITH 
A TEASPOON 



FIG. 25. — DIAGRAM SHOWING FAT PERCENTAGE OF DIFFERENT LAYERS 

OF SET MILK AND CHAPIN'S MILK DIPPER. (CHAPIX, THEORY 

AND PRACTICE OF INFANT FEEDING.) 

with a Chapin milk dipper. (Fig. 25.) Carefully pouring 
off this upper layer into a glass graduate will answer when 
the dipper cannot be obtained but the results are by no means 
as accurate. The formula of this upper third is approxi- 
mately: fat, 10 per cent.; proteids, 3 J/ per cent.; the ratio 



92 DISEASES OF CHILDREN. 

of fat to proteids being three to one. When not obtainable 
in this manner the nurse may be instructed to take equal 
parts of plain (whole) milk and ordinary cream, which con- 
tains 1 6 per cent. fat. The resulting mixture is a 10 per 
cent. milk. 

Seven per cent, top-milk is obtained by dipping off the 
upper half (16 oz.) from a quart bottle of set milk. Its equiva- 
lent in cream and milk mixtures is three parts whole milk 
and one part ordinary cream. The formula of this mixture 
is 7 per cent, fat and 3 y 2 per cent, proteids, the ratio of fat to 
proteid being 2:1. The composition of the individual layers 
of "creamed" or "set-milk" are shown in Fig. 25. 

It is advisable to make up the twenty-four hours' quantity 
in the morning, pasteurize it, and then keep the bottles on ice 
(they must be kept below 40 F.). When, however, fresh milk 
can be obtained twice daily there may be an advantage in 
making up half the daily amount at a time. This is especi- 
ally the case when raw milk of undoubted purity is being fed. 

When the child experiences difficulty in digesting the 
casein of the milk we should use barley-water as a diluent. 
As the young infant has but feeble starch-digesting power it 
is advisable to predigest the barley solution with one of the 
commercial diastatic ferments, such as Cereo, Forbes' Diastase 
or Maltine. A teaspoonful of diastase is added to a quart of 
barley water (two heaping tablespoonfuls barley flour, one 
quart water ; boil fifteen minutes and strain) when the same 
has cooled sufficiently to be tasted. 

Personally I prefer the top-milk method to the use of milk 
and cream mixtures, as it is cleaner and simpler. The table 
given below indicates the times of dilution for the different 
ages, together with the kind of top-milk to be used, the time 
for feeding and the amounts to be fed. By times of dilution 
is meant how many times as much zvater as milk is to be used. 
Thus, 5X dilution means one part top-milk and five parts 
water. When a milk and cream mixture is used the sum of 
the constituents of the food is equal to the amount of top- 



THE MODIFICATION OF COW S MILK. 



93 



milk used for a similar formula. Thus, in making up a 
formula to contain four ounces 10 per cent, top-milk and six- 
teen ounces water, if milk and cream were to be used it w r ould 
require two ounces of each. 

The composition of a given formula is readily calculated 
by simple division. For example, if we dilute 10 per cent, 
top-milk (containing 10 per cent, fat and 3H per cent, pro- 
teids) two times, the top-milk will represent one-third of the 
mixture. The mixture therefore contains 3 1-3 per cent, fat 
and 1 per cent, proteids, approximately. 

In the early months of infancy the proper ratio of fat to 
proteids under normal conditions is 3 : 1. In later infancy the 
babe can digest more proteids and the ratio is changed to 2 : 1 
with advantage. 













,? 





O 


u 












M 


= ■ X ~ - 


On 


10 £ 


■ n 















M C n. V = 


a P 


^ J3 


e - 




Age. 








p 




ntity for 
e Feed. 


c ET. 

09 _ 


- n 
-J 2 

- 7: 


Day 

Feeding. 


1-2 weeks, 


10 


^C 


fat 


5* 


10 2 hrs. 


1-2 oz. 


10-20 oz. 


2 


First Feeding, 


1*4 months, 


TO 




fat 


4x 


10 2 hrs. 


2-3 oz. 


20-30 oz. 


2 


7 A. M. 


2 months, 


IO 


% 


fat 


3* 


82^ hrs. 


3-4 oz. 


24-32 oz. 


I 




3-4 months, 


10 


9t 


fat 


2X 


7 3 hrs. 


4-6 oz. 


28-42 oz. 


I 


Last Feeding, 


5 months, 


7 % 


fat 


IX 


6 3 hrs. 


7 oz. 


42 oz. 





IO P. M. 


6-9 months, 


7 


9i 


fat 


IX 


6 3 hrs. 

1 


8 oz. 


48 oz. 


O 





3d to 14th 2d to 6th 
day. week. 

No. 1. No. 2. 






Milk, 

Cream, 

Lime-water, 

Water \ i$y 2 

Milk-sugar, .... 2)4 

(Even tablespoonfuls.) (20 oz. ) 



3 
3 

22^ 
(300/..) 



6th to 1 2th 

week. 

No. 3. 



4 
4 

22y 2 
4 

(32 oz.) 



3 to 5 

months. 

No. 4. 



12 

5 
2 

23 
(42 oz. ) 



5 to 10 
months. 

No. 5. 



18 

6 

2 
22 

(48 oz.) 



. Remarks. — These quantities and percentages are only approximate, bul 
they offer a standard by which the physician can be safely guided. It' the 
child vomits shortly after finishing its bottle, it is either getting its food 
too rapidly or in too large quantities. Regurgitation of food between 



94 DISEASES OF CHILDREN. 

In the table giving the amount of milk, cream and other 
ingredients it will be observed that the amount of milk and 
cream together represent the amount of top-milk that would 
be required to make up these formulae. Thus, substituting 
top-milk for milk and cream, formula No. i calls for three 
ounces 10 per cent, top-milk ; No. 2, six ounces 10 per cent, 
top-milk ; No. 3, eight ounces 10 per cent, top-milk ; No. 4, 
seventeen ounces 7 per cent, top-milk ; No. 5, twenty-four 
ounces 7 per cent, top-milk. 

In these formulae the ratio of fat to proteids is retained as 
three to one up to the fourth month, the first containing 1.5 
per cent, fat, 0.5 per cent, proteids, and 5.5 per cent, lactose. 
The second contains 2 per cent, fat, 0.7 per cent, proteids, 5.5 
per cent, lactose. No. 3 contains 2.5 per cent, fat, 0.8 per 
cent, proteids, 6 per cent, lactose. 

In Nos. 4 and 5 the ratio between fat and proteids stands 
two to one. No. 4 contains about 3 per cent, fat, 1.5 per cent, 
proteids and 7 per cent, sugar. No. 5 represents 3.5 per cent, 
fat, 1.75 per cent, proteids and 7 per cent, sugar (Holt). 

OTHER FOODS THAN MILK; WEANING. 

During the first year a child may take farinaceous food in 
the form of thick, strained gruels prepared from barley, rice 
or oat-meal, and added in quantities of one to three teaspoon- 
fuls to a bottle of milk. During the first half of infancy all 
farinaceous foods should be dextrinized, as the salivary glands 
and pancreas are not sufficiently active at this period of life to 
dispose of the starch. A thin gruel, such as barley-water, pos- 
sesses, besides its nutritive value, the physical property of ren- 
dering casein more digestible, as has been already pointed out. 

feedings, usually of sour milk, indicates excess of cream. Constipation, as 
a rule, indicates deficient cream or deficient quantity of food. Curds in 
the stool indicate excess of proteids or deficient proteid digestion, and calls 
for further dilution of the milk. Colic is a result either of proteid indiges- 
tion or too rapid nursing. A large, robust child naturally requires more 
food than a delicate, undersized child, and vice versa. Constant crying be- 
tween feedings, when not due to pain, signifies hunger; this, together with 
insufficient weekly gain in iveight, suggests an increased quantity or less 
dilution of the food. 



OTHER FOODS THAN MILK; WEANING. 95 

Beef-juice is a valuable food for infants who are anaemic 
or who do not thrive well on milk alone ; also in scurvy. A 
teaspoonful may be given three times daily in the latter part 
of the first year ; earlier, half that amount, excepting in cases 
of scurvy, where more is necessary. 

Orange-juice possesses decided antiscorbutic properties and 
should be administered regularly, a half to one teaspoonful 
three times daily, one hour before feeding, to infants taking 
sterilized milk or a proprietary food, or in cases of constipa- 
tion. Fresh grape-juice is likewise beneficial. 

During the first half of the second year five meals a day 
may be continued at intervals of four hours, the fifth meal 
being a bottle of milk at 10 p. m. Milk may be given in the 
bottle until the child is sixteen months old, when it should 
be taught to drink from a cup. Ten ounces of milk with a 
cereal (eight ounces of milk, two ounces of thick oatmeal or 
barley-water) will furnish the main food; this can be given 
four times daily. At the noon meal a poached Qgg or some 
chopped broiled meat (rare) on alternate days should be added 
to the dietary. Stale bread and zweibach softened with milk 
are allowable, also fiuit-juices, the soft portion of a baked 
apple and of stewed prunes. By the end of the second year, 
when all the teeth have made their appearance, a child will 
be able to take table-food of a light and digestible nature. 
Meat should only be allowed sparingly, however, and tea or 
coffee prohibited. The child should be encouraged to drink 
water freely. 

Weaning should be begun at the end of the ninth month, 
providing the mother's condition does not demand that the 
infant be taken from the breast earlier. During the summer 
months it is often advisable to carry the child along a little 
longer to forego the dangers of summer-complaint. When, 
however, gradually done and the food carefully prepared 
there is no great danger in weaning. For the first few daws 
a bottle can be substituted for a nursing; as the child be- 
comes accustomed to the bottle another can be added until 



96 DISEASES OF CHILDREN. 

the breast is eventually dispensed with entirely. As a rule, 
it can be said that a babe just weaned from the breast will 
not be able to digest a mixture of cow's milk which a babe of 
the same age that was fed by hand from birth can digest. 
We must, therefore, begin on a somewhat weaker mixture 
than one recommended for the average case. By the six- 
teenth month the child should be weaned from the bottle and 
taught to drink from a cup, excepting the 10 p. m. feeding, 
which can be given it from a bottle in bed. 

The following dietary is appended as a resume of feeding 
in later infancy : 

Diet from nine to twelve months : whole milk, six ounces ; 
barley-water, three ounces ; granulated sugar, one drachm ; 
a bottle every four hours (five feedings in twenty -four hours). 
Orange juice and meat juice also to be given as directed above. 

Diet from twelve to sixteen months : whole milk, eight 
ounces; thick barley or oatmeal-w T ater (gruel), two ounces; 
sugar, one and one-half drachms ; every four hours (five feed- 
ings in twenty-four hours). At this period oue semi-solid 
meal (a soft-boiled tgg } cereal, milk pudding, zweibach soaked 
in milk) may be given once daily as a substitute for a bottle 
of milk ; also a bottle of broth. 

Diet from sixteen to twenty four months: 7 A. M., one-half 
ounce orange juice; 7:30 A. m., a cereal, soft-boiled egg 
occasionally, eight ounces plain milk, bread and butter; n 
A. m., cup of broth with rice or barley, strained (if broth is to 
be given for dinner, this meal should be a glass of milk) 5 
2 P. m., finely-cut meat every other day, cup of broth or glass 
of milk, baked potato, or boiled rice, or a well-cooked fresh 
vegetable, bread and butter, dessert (milk puddings, junket, 
custard, gelatin, stewed fruit); 6 p. M., cereal or bread and 
milk, stewed fruit. 

During the third year the same schedule is observed but the 
variety and quantity of food is gradually increased, as all the 
teeth are present at this time the food can be of a more solid 
character and more meat allowed. 



infant's food. 97 



THE INDICATIONS FOR VARYING THE PERCENTAGES OF THE 
PROXIMATE PRINCIPLES OF THE INFANT'S FOOD. 

The character of the stool and the rate of progress in the 
child's weight are the data by which we mnst be guided in 
regulating the composition of the diet. Exceptionally breast 
milk disagrees with the child, the commonest source of dis- 
turbance being the increase in the proteids, as shown in 
Rotch's case, cited above. The symptoms pointing to this 
condition are vomiting of large curds, colic, constipation, or 
greenish stools containing tough curds. If the child per- 
sistently indulges in a food too rich in proteids, uric acid 
disturbances may develop. On the other hand, a deficiency 
of nitrogenous food leads to anaemia, a general laxity of the 
muscular system and checked physical development. 

When fats are in excess, vomiting and diarrhoea may like- 
wise be induced and the stools w 7 ill contain fat in considerable 
quantity. But when normal amounts of fat are not disposed 
of we should suspect hepatic and duodenal disturbances or 
deficient pancreatic secretion excepting in the case of tran- 
sient attacks of simple indigestion. 

A deficiency cf fat is very pernicious in its result, laying the 
foundation for the development of rickets and tuberculosis. 

The chemical instability of the carbohydrates, of which 
group lactose, cane sugar and starch constitute the most im- 
portant members, renders them especially liable to induce 
trouble, particularly when micro-organisms contaminate the 
diet. Through their fermentation lactic acid' in the one case 
and alcohol, acetic, and butyric acid in another are formed 
in the alimentary tract, and the troublesome summer diar- 
rhoeas are largely traceable to this source. Children fed over 
a long period on foods rich in carbohydrates and poor in fat 
and proteids become large, flabby, and usually rachitic. They 
are anaemic and resist acute illnesses poorly — in fact, their 
plump bodies melt down to mere bony framework, almost as 



98 DISEASES OF CHILDREN. 

a dropsy might rapidly disappear and leave an emaciated form 
behind. 

The percentages of proteids and fat can often be modified 
in breast milk by regulating the mother's diet and habits. 
Still more readily they can be changed under artificial feed- 
ing, when the condition requiring such a change presents 
itself. The amount of lactose cannot be controlled in human 
milk. Whenever a breast-fed child shows signs of disordered 
digestion and impaired nutrition it becomes necessary to 
examine the milk, in order that the proper correction of the 
condition can intelligently be made. 

THE INTERVALS FOR FEEDING AND THE QUANTITY REQUIRED 
BY THE CHILD AT DIFFERENT AGES. 

The new-born infant is put to the breast as soon as the 
condition of the mother permits. Milk is not secreted 
before the third day, but Colostrum, which is a fluid rich in 
cells from the acini of the glands undergoing fatty metamor- 
phosis, is present in sufficient quantity to appease the child's 
craving, and by its gentle laxative property empty the intes- 
tinal tract of the meconium. The child may be put to the 
breast every two hours during the first month, and if it be 
weakly, or show signs of not gaining progressively in weight, 
it may be nursed once during the night. Beginning at 5 A. 
m., and ending at 11 p. m., the child will have received ten 
nursings in all. During the second month the interval 
should be extended to two and one-half hours, and again one 
at night, if necessary. This will make eight nursings from 
5 A. m. to 11 p. M. From the third month to the time of 
weaning, which should only under rare conditions be ex- 
tended beyond the ninth month, the intervals will be every 
three hours, thus making seven nursings during the regular 
time. 

These rules should be deviated from under no circum- 
stances so long as the child is not seriously ill, and it is better 
to let it cry than give the breast before the prescribed time, 



THE INTERVALS FOR FEEDING. 99 

and awaken it when the time for nursing is due, until the 
child forms the habit of nursing regularly. 

Some authorities recommend even longer intervals than 
those given above, but it will generally be found that the 
baby does satisfactorily under this regime, and where an indi- 
vidual case is found in which a more frequent or a more ex- 
tended period seems necessary, it certainly will prove the 
wisest plan to make a change. The regularity of the feeding 
is the most important element. The advantages of this 
method over irregular feeding, or the little and often method, 
are too manifest to merit discussion. 

When the infant is to be raised by hand from the begin- 
ning, it is well to commence with a 5 per cent, solution of 
milk sugar, sterilized, one ounce every two hours for the first 
day, until the bowels have been completely emptied and the 
child is taking the liquid well. It can then be put on a mix- 
ture containing about 0.8 per cent, proteids, 2 per cent, fat and 
6 per cent, lactose ; this is gradually increased as the child's 
digestion becomes stronger, until it is taking a formula cor- 
responding to mother's milk. 

In regard to the quantity to be given at a feed no fast rule 
can be laid down, for stomachs vary in size in children of the 
same age and weight, and a child of five months may have 
the feeding capacity of another at seven months. It has been 
estimated that the stomach capacity is equal to one-hundreth 
of the child's weight ; Frowlowsky giving the following 
measurements : 

One week, 1 ounce ; four weeks, 2 l / 2 ounces ; eight weeks, 
3 1-5 ounces ; twelve weeks, 3 1-3 ounces ; sixteen weeks, 
3 4-7 ounces ; twenty weeks, 3 3-5 ounces. 

The capacity of a hand-fed babe is, however, usually greater 
than the above, and the increase after the first month is more 
rapid than this table would indicate. The average quantity 
of food required by the infant at the different periods from 
birth to the time of Weaning is given in the table on p. 93. 



100 DISEASES OF CHILDREN. 

THE STERILIZATION OF THE FOOD. 

The first milk secreted from the human breast may con- 
tain a few varieties of staphylococci, as demonstrated by Cohn 
and Neumann, these micro-organisms having gained access to 
the milk-ducts through the nipple. After the breast has been 
thoroughly drained, the micro-organisms are flushed out of 
the ducts, and the milk is then usually quite sterile. Where, 
however, the breast is diseased, tjiere may be an abundance 
of bacteria constantly present in the milk. This is the case in 
mastitis, especially in the parenchymatous variety, and in 
tuberculosis affecting the mammary gland. Under such con- 
ditions it is absolutely imperative to institute weaning. 

Cow's milk is practically never sterile ; indeed, not only 
diarrhceal diseases are brought on by the use of contaminated 
milk, but epidemics of cholera, scarlet fever, typhoid fever 
and diphtheria, beside infection with tuberculosis and foot 
and mouth diseases, have been traced directly to the milk 
supply. 

Of this group of infectious diseases cholera infantum and 
gastro-enteritis, respectively designated acute and subacute 
milk infection by Vaughn, and tuberculosis, are mainly to be 
feared, as they are constantly traceable to the method of 
feeding. 

Regarding the last-named disease, it was formerly taught 
that tuberculous cows yield milk containing tubercle bacilli, 
whether or not the udder was affected ; but the recent re- 
searches of Lewis Woodhead and Sidney Martin demonstrate 
that only milk from a cow with tuberculous udders is in- 
fectious. 

Woodhead proved also that the temperature usually rec- 
ognized as capable of destroying the tubercle bacillus, namely, 
75 C , for a period of ten minutes, was not sufficient to 
render this micro-organism innocuous ; and even when ex- 
posed twice that length of time, tuberculous milk produced 
in pigs a modified form of tuberculosis, manifesting itself as 



THE STERILIZATION OF THE FOOD. 101 

chronic tuberculous glandular and joint affections, analogous 
to scrofulosis. 

It is, therefore, highly important that all micro-organisms 
should be destroyed. Thoroughly boiling the milk for ten 
minutes renders it sterile from the clinical standpoint, or by 
subjecting it to a heat of 21 2° F. for an hour and a half in a 
steam sterilizer it will keep for several days in hot weather if 
carefully sealed. This process, however, affects the milk in 
its taste, physical properties and nutritive value. It tastes 
like boiled milk and is less digestible, the casein being ren- 
dered less coagulable by rennet and less soluble to the action 
of pepsin and pancreatin. Besides, it is believed that the 
prolonged use of sterilized milk invites the development of 
rickets and scurvy. According to Rundlett the albuminates 
of iron, phosphorus and fluorin are chemically changed by 
heating ; the globulin or proteid molecule splitting away 
from the inorganic molecule, thus rendering these salts un- 
assimilable (Fischer). For this reason many podiatrists use 
raw milk — such known as "certified," or "guaianteed milk"* 
in feeding their babies, excepting in hot weather, when it is 
safer to assume the risk of scurvy developing than cholera 
infantum or entero-colitis. Pasteurizing is preferable to steri- 
lizing, but even this destroys the germicidal action of raw 
milk which, according to Freudenthal. is one of its natural 
properties. Personally I prefer the use of raw pure milk in 
the colder months of the year. 

*The Milk Commission of the New York County Med. Soc. decided upon 
a standard to which the milk supplied to that city should conform, which 
is the following: Acidity must not exceed 2-10 of 1 per cent.; there must 
be no more than 30,000 bacteria to the c. c. , and butter fat must be present 
to the amount of at least 3^ per cent. To the dealers attaining this 
standard a certificate is to be issued and their milk known as "certified 
milk." {Med. Record, Vol. 60, No. 15. 1 

The Milk Commission of the Philadelphia Pediatric Society makes tin- 
following requirements: The specific gravity shall range from 1.029 to 1.034; 
reaction neutral or faintly acid; proteids 3.5 to 4.5 per cent.: sugar, 4 to 5 
per cent.; fat, 3.5 to 4.5 per cent. It must be free from all contaminated 
matter and from the addition of chemical substances and coloring matter. 
It must be free from pus and injurious germs and have no more than 10,000 
germs of any kind to the cu. c. {Archives of Pediatrics , March, 1902.) 



102 



DISEASES OF CHILDREN. 



Pasteurizing is practiced by immersing the bottle contain- 
ing the milk into a receptacle holding water to the level of 
the milk in the bottle. The water in the receptacle is brought 
to the boiling-point ; the bottle, stoppered with sterilized ab- 
sorbent cotton, becomes highly heated in the boiling water, 
and the source of heat having been removed, the bottle is 
allowed to remain in the hot water forty-five minutes when it 




FIG. 26. — FREEMAN PASTEURIZER.* 



is rapidly cooled under a jet of water and placed on ice. By 
this process the milk has been brought to a temperature of 
75 C, or 167 F., and maintained at that heat for an average 
of half an hour, which is sufficient for all practical purposes. 
The Freeman Pasteurizer (Fig. 26) is an inexpensive appara- 
tus and by its use much better results are obtained than by the 
makeshift method described. The Arnold Steam Sterilizer 

^Instructions for using Dr. Freeman's Apparatus for Low Temperature 
Sterilization of Milk by Pasteurization. 

1. Fill the pail to the level of the groove with water, cover it and put 
it on the stove to boil, the receptacle for the bottles having been left out. 

2. Fill the body of each bottle with milk or some modification of milk 



THE STERILIZATION OF THE FOOD. 



103 



(Fig. 27) is another good apparatus very convenient for home 
use, when sterilizing is to be carried out. 

Pasteurizing milk does not render it sterile in the bacterio- 
logical sense; it however destroys the various saprophytic 
germs that are responsible for many cases of diarrhoeas ; the 
bacillus of tuberculosis, cholera, typhoid fever, and diph- 
theria, and the organism of scarlet fever. Spores are not 
destroyed, but as it requires several days' time for their devel- 
opment any that may be present will not prove a menace to 
the child, if the food is freshly prepared daily. 

H. Lahmann (" Allgem. Med. Cen- 
tral Zeitg." Ixv., 1896) believes that 
scurvy and rickets developing in in- 
fants fed on sterilized milk is due to 
the exclusive milk diet, and not to the 
process of sterilization. Milk contains 
too small a percentage of iron, soda, 
and lime, and to remedy this defect he 
adds fruit juices to the dietary. The 
juice of oranges, cherries, strawberries, 
and other fruits is recommended, and 
after the third month this can be given 
with impunity. The evil results from 
the use of sterilized milk are not seen 
in a day — they are the outcome of 
feeding over a prolonged time. There 

is therefore no objection to the use of sterilized milk during 
hot spells, while traveling, or when an excellent quality of 
milk cannot be obtained. One should, however, always en- 
deavor to give the child raw milk whenever this is feasible. 

in proper proportion for feeding; stopper with a wad of cotton batting and 
put in a refrigerator. If all the bottles which the receptacle holds are not 
needed, fill the remaining cylinders with cold water. Each space in the 
receptacle must be filled. 

3. When the water in the pail on the stove boils thoroughly, take the 
bottles of milk from the refrigerator and put them in the spaces for them iu 
the receptacle. 




FIG. 27. — ARNOLD STKAM 
STERILIZER. 



104 DISEASES OF CHILDREN. 

If a good milk can be obtained twice daily it is rarely neces- 
sary to sterilize or pasteurize, excepting as before stated dur- 
ing hot spells, and also, when there is a tendency to diar- 
rhoea. 

Even the continued use of pasteurized milk may bring with 
it the appearance of signs of rickets and even scurvy. Sill (JV. 
Y. Med. Record, Dec. 27, 1902) claims that in 97 per cent, of 
a long series of infants under his observation that were fed 
on pasteurized milk there were unmistakable signs of rickets 
or scurvy, or a combination of these diseases. On the other 
hand we occasionally see perfectly healthy infants that have 
been on pasteurized milk since birth. 

4. Pour cold water into each of these spaces so as to surround the body 
of the bottle. 

5. Take the pail of boiling water from the stove and put it on a table 
or mat. Do not put it on metal or stone. Be sure that the pail is still filled 
exactly to the level of the groove and that the water is boiling vigorously. 

6. Set the receptacle containing the bottles of milk into the pail of boil- 
ing water, so that the wire (a) will rest on the support (c), cover the pail 
quickly and let it stand forty-five minutes. During this period the pail 
must not be on the stove and the cover must not be removed. 

7. Now uncover the pail and lift the receptacle and turn it so that the 
wire (b) will rest on the support (c), thus elevating the top of the receptacle 
above that of the pail. Put the pail containing the receptacle elevated in 
this manner in a basin under a faucet to which a rubber pipe ma)* be at- 
tached connecting it with the pail (Fig. 2). The water will overflow from 
the pail into the basin. Or the pail may be stood under a pump, fresh cold 
water being pumped into it every few minutes. 

The above described method of cooling is the best. When, however, it 
is not possible to cool the milk in this way, the cooling may be accomplished 
by placing the receptacle containing the bottles of milk in iced water, or by 
simply standing the bottles on wood in a refrigerator. 

8. To warm the milk for use, put the bottle containing it in a vessel of 
cold water on the stove, and leave it until it is warm. Use a fresh bottle for 
each feeding. 

9. Wash the bottles thoroughly after using, and once a day put all the 
empty bottles in a kettle of cold water on the stove aud let this water boil 
for an hour. The bottles should then be taken out and stood bottom up 
until used. 

Milk sterilized by this apparatus may be used for food during the follow- 
ing twenty-four hours. 

The Freeman Pasteurizer is manufactured by James T. Dougherty, 409 
and 411 West 59th Street, New York City. 



ARTIFICIAL FOODS. 105 

THE PREPARATION AND INDICATION FOR OTHER FOODS AND 

ADJUVANTS TO THE CHILD'S DIETARY. 

ARTIFICIAL FOODS. 

Barley -Water. — This is a most useful adjuvant in the 
treatment of many conditions peculiar to infants. According 
to a series of experiments by Cautley, a weak barley-water 
will render the curds of milk, when precipitated by acetic 
acid, much finer than is the case with any other diluent. It 
is a bland, demulcent liquid, possessing some nutritive prop- 
erties, mainly from the presence of starch. It should there- 
fore be used cautiously until the amylotic functions of the 
saliva and pancreatic juice have been developed. Being de- 
mulcent, and containing a carbohydrate element which is not 
so favorable a medium for the development of micro-organisms 
as a proteid it is especially serviceable in the acute summer 
diarrhoeas of infants, either as an attenuant of the milk or 
when given pure. It is best made as follows : " Take two 
ounces of pearl barley and wash well with cold water, reject- 
ing the washings. Afterwards boil with a pint and a half of 
water for twenty minutes in a covered vessel, and strain." — 
(Pavy.) A quicker method is to make it from barley flour, 
a tablespoonful to the quart, boiled fifteen minutes. 

Rice-Water. — This is a very nutritious, soothing drink in 
acute intestinal troubles. " Thoroughly wash one ounce of 
rice with cold water. Then macerate for three hours in a 
quart of water kept at a tepid heat, and afterwards boil slowly 
for an hour, and strain." — (Pavy.) 

Rice-Paste.— Dr. George B. Fowler (" N. Y. Med. Record," 
No. 12, 1890) highly recommends a paste, made by adding 
four tablespoonfuls of rice to three pints of water, boiling 
half an hour and then setting aside to simmer, water being 
occasionally added to maintain the three pints. This is 
strained through a colander and cooled, when a paste is 
formed. Three tablespoonfuls of the paste are added to half 
a pint of sterilized milk. Dr. Alonzo Barnes of this city has 
8 



106 DISEASES OF CHILDREN. 

had excellent results from this preparation in summer-com- 
plaint. Rice is perhaps the most readily assimilated starchy 
food. 

Oatmeal- Water. — This is contraindicated in diarrhceal af- 
fections, but is useful as a diluent in constipation. A table- 
spoonful of oatmeal is added to a pint of water and brought 
to the boiling-point under constant stirring. It is then set 
aside, allowed to cool, and strained. 

Albumen- Water. — This is a highly nutritious, easily di- 
gested drink, and is often retained where the stomach rebels 
against more substantial forms of food. " Take the white of 
a fresh egg and cut it in various directions with a clean pair 
of scissors. Shake it up in a flask with a pinch of salt and 
six ounces of pure cold water. Strain through muslin." 

Beef Tea. — It is needless to mention here that beef tea con- 
tains no virtue beyond its stomachic and stimulating effects. 
It is useful in low, febrile conditions and where there is lack 
of reaction. In order to render it nutritious, beef pulp or a 
cereal must be added. 

Chicken- and Mutton-Broth. — These broths are less stimu- 
lating than beef tea, but are better tolerated where there is 
much fever. Chicken broth contains some gelatin. 

Beef Juice. — When properly prepared, this is a highly 
nutritious albuminous form of food. It is an excellent food 
in anaemia and where the digestive powers are weak, but 
lithaemic symptoms must be watched for when used over 
an extended period. To obtain the juice, a piece of 
sirloin steak, or any good piece of beef from which the 
fat and connective tissue have been removed, is quickly 
broiled in a hot pan, placed in a strong lemon squeezer, or, 
better still, the beef press, especially made for this purpose, 
and the juice squeezed out. It may be served warm with 
seasoning or on bread ; also diluted with ice-water. Boiling 
coagulates the myosin and serum albumin, and renders the 
product less digestible. 

Junket is often useful to vary the monotony of a milk 



ARTIFICIAL FOODS. 107 

diet. It can be prepared with rennet or Fairchild's essence 
of pepsin. 

Peptonized Milk. — This is a most satisfactory food in low 
typhoid states and sometimes in dyspeptic cases, used until 
the digestion has regained its normal condition. For rectal 
feeding it is extremely valuable. The milk used for this pur- 
pose must not be rich in cream. — (Gilman Thompson.) 
The quickest and most satisfactory method of preparing it is 
to dissolve the contents of a Fairchild's peptonizing tube in 
four ounces of cool water, adding a pint of milk. The bottle 
containing the mixture is placed in hot water of a tempera- 
ture that can be borne by the hand for a minute without dis- 
comfort (Starr), and allowed to remain thirty minutes. If 
this renders it too bitter, it should be removed earlier. 

Peptogenic Milk-Powder. — This is a powder containing 
the pancreatic ferment and milk sugar. By adding it to a 
mixture of cream, milk and water, we obtain a modified milk, 
resembling human milk in composition and one in which 
the casein is at the same time partially predigested. It is 
well adapted to infants with weak or poorly developed 
digestive organs ; I have seen it do good in premature and 
under-developed infants. A mixture of one-half pint milk, 
one-half pint water, four tablespoonfuls of cream and four 
measures of peptogenic milk powders makes a close imitation 
of human milk in composition. The process of peptonizing 
is essentially the same as in the case of the peptonizing tube 
above referred to. It can, therefore, be checked by bringing 
the milk to a boil or continued by keeping it warm (at 115 
F.). As the child's digestion improves the peptonizing pro- 
cess should be shortened until the milk is tolerated in its 
natural state. 

Malt Diastase — Liebig's Food. — Ground malt possesses 
marked diastatic properties, and when added to a starchy 
food, converts the latter into maltose. Malt extracts have 
the same power, but to a less degree. In amylaceous dys- 
pepsia the child's farinaceous food, such as oatmeal, rice, 



108 DISEASES OF CHILDREN. 

cracker-paps and flour soup, should be sweetened with a malt 
extract instead of cane sugar. It can also be given alone be- 
fore meals. L,iebig's food contains gluten — the proteid of 
wheat and barley — dextrin and maltose. It is prepared as fol- 
lows : u Mix a half-ounce each of ground malt and wheat 
flour, seven and one-fourth grains of potassium bicarbonate, 
with one ounce of water and five ounces of sweet cow's milk. 
Warm slowly and stir until thick. Remove from fire, stirring 
for five minutes ; replace over fire and remove when quite 
thick." — (Gilman Thompson.) This mixture becomes thin 
and sweet as the diastatic process becomes completed, when 
it is again boiled and strained. Fothergill is a great advo- 
cate of ground malt. He recommends it in addition wdth 
baked flour and hot milk. Maltine is a very stable article, 
and, beside being a digestive agent, is rich in phosphorus 
and other food elements. When a mild stimulant is indi- 
cated, a liquid preparation, such as Hoff^s, is very useful. 

Baked Flour. — Through the process of baking the starch- 
granules are burst, and some of the starch is converted into 
dextrin, making it, on the whole, more digestible. A water- 
cracker is a good example of baked flour, but it contains 
some lard, which is necessary in the process of manufacture. 
As most infant foods are deficient in fat, it is rather an ad- 
vantage than otherwise ; and if these crackers are rolled to a 
fine powder, stirred to a paste with cold water, and boiled 
with sufficient milk to make a thin pap, we have here a 
highly-nutritious food, easily digested by most babies after 
the sixth month. It can be sweeted with a malt preparation, 
which will prevent constipation. Comparing this food with 
the artificial foods flooding the market, we can see readily 
that the only advantage they have over simple home methods 
of preparing foods is the rapidity with which they are made 
and the saving of a little trouble. They are expensive, 
usually insufficiently nutritious, not always conforming to 
the formula advertised by the manufacturer, and, although 
they will save the mother a little trouble for the time being, 



ARTIFICIAL FOODS. 109 

she will be fortunate, indeed, if the expense and worriment 
attached to the development of tuberculosis, scurvy and rickets 
be spared her at a later date. 

Fruit Juices. — In a previous chapter the necessity of 
using fruit juices where there is a tendency to scurvy and 
rickets was pointed out. Where fresh fruit cannot be 
obtained, the sweetened juice of dried plums, apples, apri- 
cots and the like can be used. In constipation they are often 
called for. 

Fat — Cod-Liver Oil. — It may be that fat has been insuf- 
ficiently supplied in the child's dietary, or that the child can- 
not properly digest and assimilate it. In the latter case 
cod-liver oil often comes to the rescue. It is best given as 
recommended by Fothergill, i. e., taken about an hour after 
eating, when the food passes out of the stomach into the 
duodenum. In this way it does not needlessly provoke 
the stomach, and the disagreeable eructations are avoided. 
Sometimes an emulsion acts better than the pure oil. 

The marrow from a shin-bone spread on bread while hot, 
and a little salt added, is an excellent food for anaemic chil- 
dren. Fat is the necessary food in struma and rickets. 
Butter-taffy is a pleasant way of supplying fat when cod- 
liver oil is refused, and is highly praised by Fothergill. 

Stimulants. — Brandy, well diluted, is the best alcoholic 
stimulant. Beginning with half an ounce, the quantity can 
be increased to one ounce in twenty-four hours for a child one 
year old. I have often substituted alcohol sponge-baths (one 
part of alcohol to three parts water), and a compress of dilute 
alcohol applied to the abdomen, for the internal administra- 
tion of alcohol, with entire satisfaction. Eggnog is an excel- 
lent stimulant and food in convalescence from acute illm 
it is also valuable in the debility of phthisis. Malt extracts 
have been referred to. 

Artificial Foods. — Any one who has taken the trouble to 
acquaint himself with the method of modifying cow's milk to 
resemble human milk in composition, and has observed the 



110 DISEASES OF CHILDREN. 

results obtained from this method of feeding, and also has 
studied the simple method of preparing suitable articles of 
diet for the child in health and in disease, as detailed above, 
must fail to see any special necessity for the numerous pro- 
prietary foods so extensively used and advertised. And yet 
there is a field for them ; there are times when it is extremely 
convenient to have an article at command requiring simply 
the addition of hot water or milk for its preparation, and at 
the same time know that we can rely on it and get results. 
The mistake is to use a prepared food over a prolonged 
period of time, for then the mischief is done, but if we em- 
ploy these foods with judgment, they are very useful. For ex- 
ample, Horlicfcs Malted Milk is often retained when other 
food is vomited ; it requires simply the addition of boiling 
water in its preparation, and will sustain life for a long period 
of time. It is, therefore, an excellent food to be used in 
travelling and in some acute conditions. A cup of hot 
malted milk at bedtime is conducive to restful sleep, this 
action being usually very marked and to be relied upon, more 
so than from the use of plain milk, no doubt owing to its 
greater digestibility. 

Condensed Milk contains too much sugar and too little fat 
to be a suitable infant's food, being only permissible in case 
of emergency. Evaporated milk, without the addition of 
sugar, prepared from a milk rich in fat, is a much better sub- 
stitute for fresh milk. 

Mellin's Food is a Liebig Food and can be used when it is 
not convenient to prepare the Liebig food at home. It is 
useful in constipation, and is very fattening. When made 
according to directions it closely resembles mother's milk, 
but it must be remembered that the cow's milk which is 
added to this food is the main factor in the formula. 

The Allenbury's Foods are excellent artificial foods made 
in a series of three formulae, the composition of each aiming 
to correspond to the needs of the different periods of infancy. 
The milk food, No. i, is to be used during the first three 



ARTIFICIAL FOODS. Ill 

months of infancy. It contains casein, fat and sugar in the 
correct proportion required for the digestive powers at this 
age. Food No. 2 is similar to the No. I, but contains in ad- 
dition a certain amount of maltose, dextrose, soluble phos- 
phates and albuminoids. It is intended for the third to sixth 
month. The food No. 3 is essentially a farinaceous food, re- 
quiring the addition of cow's milk in its preparation. It is 
intended for children of six months and upward. The manu- 
facturers of these foods, willing to admit that scurvy and 
rickets are likely to occur in children fed exclusively upon 
artificial foods over an extended period of time (to say nothing 
of malnutrition), wisely suggest the daily use of a dessert- 
spoonful of grape or orange juice to be given two or three 
times a week after the third month, and later on also raw 
meat juice. 

Artificial foods, therefore, have their place ; they are never 
absolutely necessary, only being convenient contrivances of 
our progressive age, and they can never supplant mother's 
milk or cow's milk modified by strictly scientific methods. 



CHAPTER V. 

DISEASES OF THE NEW-BORN. 

A variety of pathological conditions is to be observed in 
the new-born, resulting either from mechanical injury or from 
infection. Certain physiological changes taking place in the 
organism may also give rise to disturbances peculiar to this 
period of life ; these are notably asphyxia, cyanosis, and 
icterus. 

ASPHYXIA. 

Asphyxia of the new-born may be either of intra- or extra- 
uterine origin. Intra-iiterine asphyxia results from the in- 
terruption of the placental circulation through compression 
of the cord or premature separation of the placenta. Respi- 
ratory efforts are excited in ; the child through the resulting 
carbonization of the blood and the lungs consequently 
become rilled with amniotic fluid. 

Extra-uterine asphyxia presents itself immediately on or a 
short time after birth. The degree of asphyxia may be of 
several grades, varying from a simple interference with the 
respiratory function from the collection of mucus or other 
foreign substances in the pharynx and trachea to complete 
cessation of respiration. In the latter case the child may be 
robust when born and present all the signs of active asphyxia, 
the body surface being cyanotic and the face bloated (sthenic 
asphyxia) ; or it may be pallid and limp and apparently life- 
less (asthenic asphyxia). A frequent cause of the asthenic 
form is pial hemorrhage, the irritability of the respiratory 
centres being abolished through the intra-cranial pressure. In 
the absence of haemorrhage, malformations of the respiratory 
or circulatory organs, pulmonary atlectasis, pulmonary syph- 
ilis, pneumonia or premature birth may be mentioned as 
causes. 



HEMATOMA OF STERNO-MASTOID MUSCLE. 113 

• The results of asphyxia are stagnation of dark, fluid blood 
in the veins and filling of the right ventricle, hyperaemia of 
the various organs, and petechial haemorrhages. 

The reflexes are not abolished in the sthenic variety and 
the pulse is slow but perceptible. It presents a better prog- 
nosis than the asthenic variety, in which there is pallor of 
the body surface, abolition of reflexes, and imperceptible 
pulse. 

The treatment consists in the removal of all obstruction 
such as mucus and amniotic fluid from the air-passages, sup- 
plemented by measures calculated to set up respiratory efforts 
through peripheral irritation. The alternate warm and cold 
bath is very efficacious. In the asthenic variety the warm 
bath alone should be employed, together with artificial res- 
piration, but when the asphyxia is only a symptom of one of 
the serious conditions above enumerated, the prognosis is 
utterly hopeless. 

CEPHALHEMATOMA. 

A cephalematoma is a tumefaction situated upon one of the 
cranial bones, usually the parietal, caused by haemorrhage 
beneath the periosteum. It results from injury sustained dur- 
ing parturition, and is frequently encountered in children 
born through a narrow pelvis. Being entirely external no 
symptoms are induced thereby, the clot becoming organized 
and absorbed in the course of several weeks. Usually it does 
not become manifest until a few days after birth and may be 
confounded with hernia cerebri, but the latter is most fre- 
quently situated either at the root of the nose or the nape of 
the neck, and presents a distinct bony edge, indicating the 
opening from which the sac protrudes. No treatment is re- 
quired. 

HEMATOMA OF STERNO-MASTOID MUSCLE 

This usually affects the belly of the right stenlo-mastoid 
muscle, most commonly appearing after breach Labors, being 



114 DISEASES OF CHILDREN. 

the result of twisting of the head during parturition. A firm 
elastic, egg-shaped swelling appears in the middle of the mus- 
cle about two weeks after birth and is accompanied by torti- 
collis. It disappears in the course of a few weeks and re- 
quires no treatment, excepting such measures as will hasten 
absorption, namely, hot fomentations and Arnica internally. 

INTRACRANIAL HEMORRHAGES. 

Apoplexy of the new-born is encountered as a venous or 
capillary haemorrhage of the meninges of the brain, less fre- 
quently taking place into the cortex. It results from direct 
injury sustained during birth. This condition is fully dis- 
cussed under cerebral palsies. Other forms of injury to the 
nervous system encountered at this period are facial and 
brachial paralyses, resulting from pressure or traction upon 
the nerve trunks supplying these parts. 

SEPTIC AND OTHER INFECTIONS IN THE NEW-BORN. 

Septic infection in the majority of instances takes place 
through the umbilicus. There may, however, be an intra- 
uterine infection through the placenta or by the aspiration of 
amniotic fluid containing pathogenic micro-organisms. Again, 
an abrasion of the skin or of the mucous membranes may 
give entrance into the system of germs. When the port of 
entrance cannot be discovered the infection is spoken of as 
" cryptogenic." 

The pathological findings depend upon the mode of infec- 
tion. Often it is impossible to find the site at which infec- 
tion took place and the evidences of septicemia alone exist. 
There is fever ; rapid and shallow respiration, vomiting, diar- 
rhoea and wasting. Collapse with a fatal termination is the 
usual outcome. Symptomatic icterus and internal haemor- 
rhages are associated conditions. 

i. In the cases in which infection takes place through the 
respiratory tract, the evidences of septic pneumonia, fre- 
quently with bloody extravasations into the pericardium and 
pleura, are found. 



SEPTIC. AND OTHER INFECTIONS IN THE NEW-BORN. 115 

2. Infection through the umbilicus gives rise to either a 
local or general sepsis. Under the heading of the former are 
included umbilical arteritis, phlebitis and omphalitis. In 
omphalitis there is an involvement of the surrounding cellu- 
lar tissues and suppuration results. It occurs most frequently 
during the second and third weeks. The prognosis is good 
under prompt surgical treatment, but extension to the perito- 
neum with general sepsis may occur. 

General sepsis originating in infection through the um- 
bilicus is almost invariably associated with peritonitis. Be- 
sides this localization there may also occur septic pleuro- 
pneumonia ; pericarditis ; meningitis ; gastro-enteritis ; osteo- 
myelitis and arthritis. The most frequent of these conditions 
is peritonitis ; the next in frequency being pneumonia, then 
pleurisy ; meningitis ; meningeal haemorrhage ; entero-colitis ; 
pericarditis and meningeal haemorrhage, in the order as 
named (Bednar). 

3. There are also a number of infectious conditions not 
originating in the umbilicus. They are as follows : 

Erysipelas. — The distinct type of cellulitis resulting from 
infection with the streptococcus pyogenes is occasionally en- 
countered in the new-born. An abrasion of the skin or 
mucous membrane is the usual site of infection, although it 
may originate in the umbilicus. In the latter instance a fatal 
termination is the rule. 

The remedies most useful are Belladonna, Apis, Rhus tox., 
and Graphites. Locally a 10 per cent, aqueous solution of 
Ichthyol proves a valuable adjuvant. Painting the border of 
the affected area with Collodion to check its spread has not 
proven of much value in my hands. In the severe cases com- 
plicated with omphalitis or phlegmon the stronger antiseptics 
must be applied locally. 

Tetanus. — The bacillus of tetanus may be inoculated at 
the site of an abrasion of the skin or of a mucous membrane, 
or it may gain entrance through the cord. Infection at the 
umbilicus usually occurs at the time of the separation of the 
stump of the cord. 



116 DISEASES OF CHILDREN. 

The symptoms are identical with those observed in the 
adult, the earliest manifestation being rigidity of the jaws, oc- 
curring as stated above, shortly after the separation of the 
cord-stump. This trismus is followed by tonic spasms of the 
muscles of the neck and extremities, occurring paroxysmally. 
As a rule, it terminates fatally within a few days, although it 
may pursue a protracted course and result in recovery. 

The disease is by no means as frequently encountered now 
as it was in the pre-antiseptic days, when no precautions 
were taken in the dressing of the cord and when the granu- 
lating surface left after the separation of the stump was not 
protected against the invasion of germs. 

The treatment is both local and internal. The site of in- 
fection should be dressed with gauze wrung from a one in 
two thousand solution of the bichloride of mercury in order 
to check the further progress of infection, and if there be a 
focus of suppuration, free drainage must be instituted. 
Hypericum may be administered with the hope of influenc- 
ing the course of the disease. Other remedies that have been 
recommended are Belladoitna, Cicnta, Hydrocyanic acid, 
Lachesis, Nux vomica, Physostigma and Stramonium, 

Tetanus Antitoxin, although a tiue antitoxin, has not as yet 
displayed a perceptible advantage over other methods of 
treatment, nevertheless its use should not be omitted. As the 
poison of tetanus is an intracellular toxin, only the very early 
use of the serum offers any hope of cure. In order to relieve 
suffering, if our remedies fail to act favorably, Chloral hydrate 
in one-half grain doses should be administered. Fifteen 
grains daily may be used. When given per rectum twice 
that amount is necessary. Hot bottles should also be tried, as 
they enhance the action of the drug and give much relief. 
The narcotics are of less value. 

ACUTE FATTY DEGENERATION, OR BUHL'S DISEASE. 

This disease was first described by Buhl in i860, and pre- 
sents parenchymatous inflammation, fatty degeneration and 



OPHTHALMIA NEONATORUM, 117 

haemorrhages in the heart, liver and lungs. It is probably of 
infections origin. It is rare, and is only seen in lying-in 
hospitals. The children are usually born asphyxiated, and 
they do not entirely recover from this state. Cyanosis super- 
venes, and they either die at this time, or the course of the 
disease is protracted, and bloody diarrhoea, haemorrhage from 
the navel, mouth, nose and conjunctiva, and icterus, set in. 
Later, oedema of the skin occurs, and death from collapse fol- 
lows at about the end of the second week. The diagnosis can 
only be positively made by a microscopic examination of the 
organs. The course is always fatal. 

ACUTE HEMOGLOBINURIA, OR WINKEL'S DISEASE. 

In 1879 Winkel encountered a series of twenty -three cases 
of hsemoglobinuria occurring in the new-born, associated with 
cyanosis, icterus, and haemorrhages in the various organs, 
with a fatal termination within thirty-two hours in the 
average of cases. The cause is unknown, but it is undoubt- 
edly an infection. Other cases have been reported, but not in 
such an extensive epidemic as the above. — (Winkel, Lehrbuch 
der Geburtshiilfe^ Ham ill and Nicholson in a series of care- 
fully studied infections in the new-born {Archives of Pediatrics, 
Sept., 1903) have found that a variety of micro-organisms 
is to be encountered, showing that careless nursing is most 
likely at the bottom of these infections. They would include 
Winkel's disease, Buhl's disease and melena among the acute 
infections of the new-born, although haemorrhagic conditions 
at this time of life may also be the result of syphilis, asphyxia, 
trauma and malformations. 

OPHTHALMIA NEONATORUM. 

The violent conjunctivitis of the new-born, which at times 
results in destruction of the entire eye is due to infection 
with the gonococcus of Neisser. When the infant is infected 
during parturition, the symptoms make their appearance on 
the third or fourth day ; in some instances the eyes are 



118 DISEASES OF CHILDREN. 

probably infected later and symptoms do not arise until a 
week or more. 

The first indication of the trouble is redness and swelling 
of the palpebral and ocular conjunctiva, pufhness of the eye- 
lids and catarrhal secretion. The secretion rapidly becomes 
purulent and the eye-lids infiltrated and leathery. In viru- 
lent cases chemosis is pronounced and the cornea is deprived 
of its nutrition through compression of the blood vessels at 
the sclero-corneal margin. The cornea becomes opaque, its 
epithelium is desquamated and perforation may result. 

A benign, non-gonorrhceal form is also encountered. This 
is recognized by its mild course and by the microscopic ap- 
pearance of the secretion which contains the ordinary pyo- 
genic organisms. 

The prognosis must always be guarded ; it is especially un- 
favorable in cases that have progressed before treatment is 
instituted. It is claimed that from 25 to 30 per cent, of 
blindness can be accredited to ophthalmia neonatorum. 

Treatment. — On the first indication of ophthalmia the eyes 
should be irrigated hourly with a 2 per cent, solution of 
Boric acid and covered with compresses wrung from ice 
water or laid on a cake of ice and kept constantly applied and 
changed when they become soiled and warm. As soon as the 
discharge becomes thick and creamy, a few drops of a solu- 
tion of Nitrate of Silver, three to four grains to the ounce 
should be instilled into the eyes two to three times daily. At 
the same time, as the discharge increases, it is better to resort 
to frequent irrigation of the eyes with warm Boric acid solu- 
tion every twenty minutes if necessary, and discontinue the 
compresses. A bad case will engage the entire attention of 
two nurses, one for the day and the other for the night. 
With the subsidence in the inflammation and when the eye- 
lids loose their infiltrated character, a few drops of a 4 per 
cent, solution of Nitrate of Silver should be dropped upon 
their everted surface, taking care not to allow it to run into 
the eye. This may be followed by irrigating with normal 
salt solution. 



ICTERUS NEONATORUM. 119 

In order to satisfactorily inspect the cornea from day to 
day and to properly flush out the conjunctival sacs, it is well 
to make use of retractors. Should Nitrate of silver appear 
too irritating, Protargol in a i or 2 per cent, solution may be 
substituted. 

When the cornea becomes involved a drop of a 1 per cent, 
solution of Atropine sulph. must be instilled twice daily. In 
threatening perforation, Eserine may be tried. Internally, 
Aconite in the early stages; Arg. nit. later. The responsi- 
bility of these cases is so great that an oculist should always 
be taken in consultation. 

MASTITIS. 

Inflammation of the mammae with abscess formation is a 
common result of squeezing out the breasts in a rough man- 
ner. In the new-born there is frequently present a cholos- 
trum-like secretion and any form of mechanical irritation of 
such a breast is likely to result in inflammation and suppura- 
tion. Under the use of hot fomentations and the administra- 
tion of Belladonna or Bryonia according as the symptoms of 
either of these predominate, followed by Hepar, resolution 
promptly results. 

ICTERUS NEONATORUM. 

Icterus may occur symtomatically as a hematogenous jaun- 
dice in septicaemia, Buhl's disease and Winkel's disease, or it 
may be due to congenital or syphilitic stricture of the hepatic 
duct. 

A physiological icterus occurring several days after birth, 
disappearing spontaneously in the course of a week, is ob- 
served in from 79 to 84 per cent, of all infants (PORAK, 
Cruse). It most frequently occurs when birth lias been pre- 
mature, or if litigation of the cord has been delayed. Accord- 
ing to Birch-Hirschfeld, swelling of the capsule of Glisson 
takes place from interruption of the circulation in the umbil- 
ical vein, with resulting pressure upon the biliary ducts 



120 DISEASES OF CHILDREN. 

and hepatogenous jaundice. Hofmeier is of the opinion 
that the icterus is haematogenous in origin, depending upon 
an extensive destruction of red blood corpuscles, a process 
which takes place in the liver most actively at this period of 
life. Stadelmann positively denies the existence of hsemato- 
genous icterus and he claims that the pigment found in the 
urine in pernicious anaemia, malaria and acute yellow atrophy 
of the liver is urobilin and not bilirubin. The concensus of 
opinion however seems to be favorable to the view that in 
icterus neonatorum there are two factors active, namely, fall 
of blood pressure in the hepatic circulation so that the press- 
ure in the bile ducts becomes greater than in the hepatic 
veins, and excessive destruction of red corpuscles, making it 
impossible for the liver to transform all the pigment into 
bilirubin. 

CEDEMA. 

In delicate, feeble infants during early life, a general 
oedema, affecting at first the eyelids and the dorsum of the 
hands and feet, and if it progresses, involving the entire 
cutaneous surface, may develop as a result of a feeble heart 
muscle. The kidneys are normal in these cases. Ascites 
seldom occurs. It has been suggested that some toxic agent, 
probably of gastro-intestinal origin may affect the lymphatics 
and thus set up the oedema. Kali carb. seems the best 
indicated remedy. 

GASTRO-INTESTINAL HEMORRHAGE, OR MELENA. 

Haemorrhage from the stomach and bowels may take place 
shortly after birth, and terminate fatally within a few days. 
These haemorrhages may result from congestion and slight 
erosion of the mucous membrane of the lower bowel (as a 
result of thrombosis of the umbilical blood vessels or as- 
phyxia), follicular ulceration of the stomach and intestines, 
or from a round, perforating ulcer, and also from any of the 
infections above mentioned, beside constitutional diseases. 



GONORRHOEA. 121 

The possibility of follicular ulceration of the stomach and 
bowels existing in infants who have died suddenly without 
having displayed any of the symptoms of melena, either in 
the vomiting of blood or the passing of bloody stools, has 
been impressed upon me on several occasions by post-mortem 
findings. The pathology of this condition is more fully de- 
scribed under the diseases of the stomach. Etiologically 
these haemorrhages undoubtedly belong to the infections of 
the new-born. The distinctive symptoms, bloody vomitus 
and bloody stools would indicate such remedies as Hama- 
melis (abdomen sore to touch, haemorrhage profuse, dark, or 
clots mixed with mucus) Merc. cor. (tenesmus; bright blood) 
Argentum nitr. (ulceration of stomach) Arsenicum (great 
prostration ; septic cases). Other remedies may be suggested 
by the child's general condition. Supra-renal extract in one- 
half grain doses is the most satisfactory hemostatic in gastric 
haemorrhage. 

GONORRHOEA. 

The most common form of infection is of the eyes. Bag- 
insky has recently reported the case of a male new-born in 
which genital gonorrhoea developed. Of late years frequent 
attention has been called to the prevalence of gonorrhceal 
arthritis in infants. There is no doubt that the majority of 
cases of acute arthritis in infants is gonorrhceal. General 
septic infection with polyarthritis and constitutional symp- 
toms occur. I have recently had such a case in which Dr. 
Sappington was able to demonstrate the gonococcus in the 
pus from the joints. The course was protracted and the in- 
fant died from exhaustion. The arthritis was preceded by 
gonorrhoeal ophthalmia. Kimball (A 7 . Y. Record, Nov. 14, 
1903) has reported eight cases of gonorrhoeal pyaemia in 
infants. In none of his cases was a local infection demon- 
strable. These cases proved fatal. The temperature is ir- 
regular and usually runs high. Many joints may be affected, 
even the fingers and toes, and the fusiform swelling of a finger 
9 



122 DISEASES OF CHILDREN. 

may lead us to suspect tuberculosis or syphilitic dactylitis if 
we are not on our guard. The polyarthritis however elimi- 
nates these conditions. Other foci of pus are found scattered 
throughout the body. 

SUDDEN DEATH IN INFANTS. 

Sudden death in the new-born is most frequently due to 
visceral haemorrhages resulting from compression of the head 
during birth or from haemorrhage into the internal organs. 
The latter is more frequent in breach cases, no doubt as a 
result of improperly made traction. 

Malformations of the viscera, either demonstrable or unsus- 
pected, are common causes of sudden death in young infants. 
Here may be discussed thymic death, a subject in which re- 
newed interest has been shown only in recent years. While 
Paltauf denies that pressure from the thymus plays a role in 
the sudden death of these infants, attributing it to the clini- 
cal entity he has termed status lymphaticus, or lymphatism 
(see Constitutional Diseases), still the theory that thymic death 
can occur has many adherents, notably in Jacobi. The latter 
writes : "It [the thymus gland] is largest, normally, from the 
third to the twentieth month ; about the ninth month it was 
found, in usual instances, from 1.5 to 2 centimetres in thick- 
ness. As the distance between the manubrium sterni and the 
vertebral column is but two centimetres about the eighth 
month of life, the slightest increase of an enlarged thymus 
through distended circulation, by crying or otherwise, may 
prove suddenly fatal ; for besides the thymus, the oesophagus, 
the trachea, the blood vessels, and the sympathetic and pneu- 
mogastric nerves are located in that narrow space. Bending 
the head backward during tracheotomy proved fatal. Swell- 
ing of the thymus in a cold bath may be dangerous" (Thera- 
peutics of Infancy and Childhood). In discussing a case re- 
cently reported by Caille (Archives of Pediatrics, March, 1903) 
Jacobi called attention to the fact that but a few of the in- 
stances are on record since Kopp reported his first case of 



SUDDEN DEATHS IN INFANTS. 123 

thymic asthma nearly a hundred years ago. He related a 
case operated upon by Konig in which the gland was partly 
excised with life-saving results. For detailed report on this 
subject the reader is referred to Jacobi's monograph (Trans. 
Ass. of American Phys., Vol. III.) and to Fried Jung's article 
(Archive fur KinderheUk.^ Vol. 29). 

Atelectasis. — This is either congenital or acquired. Com- 
plete atelectasis is seen in asphyxia neonatorum. In feeble 
infants atelectasis may develop after the lungs have been func- 
tionating, and if progressive it results in death. It is simply 
a manifestation of a general lack of resistance in the infant 
to its environment. During the course of bronchitis or 
broncho-pneumonia areas of atelectasis develop from the oc- 
clusion of the finer bronchial tubes. In some cases of ma- 
rasmus nothing is found post-mortem excepting pulmonary 
atelectasis. 

Asphyxia from the aspiration of food into the larynx is at 
times found to be the cause of sudden death in feeble infants. 
Sudden death may arise from laryngismus stridulus or in gen- 
eral convulsions, the determining cause being asphyxia. A 
retro-pharyngeal abscess or the pressure of tuberculosis bron- 
chial glands upon the pneumogastric nerves or trachea may 
likewise cause sudden death. 

Sudden death after a few hours of illness with high tem- 
perature is as a rule due to congestive pneumonia (Holt). An 
infant several days old dying suddenly with high temperature 
and rapid respirations, at the Hahnemann Maternity during 
Dr. Korndoerfer's service, showed at autopsy a large haemor- 
rhage from the right middle meningeal artery following for- 
ceps delivery. The chief interest in the case rested in the 
utter absence of cerebral manifestations. 

Sudden death may occur in the first twenty-four hours of a 
malignant scarlet fever before the eruption has made its ap- 
pearance. 



CHAPTER VI. 

DISEASES OF THE MOUTH. 
DENTITION. 

The period of dentition represents the time during which 
the milk teeth make their appearance, and extends normally 
from the seventh month to the second year. The period of 
second dentition begins with the sixth year and is usually com- 
pleted before puberty, with the exception of the wisdom 
teeth, which may appear as late as the twenty-first year. The 
term "teething" applies to the first dentition period, and em- 
braces the various disturbances occurring at this time, when 
they can be directly traced to the teething process. 




FIG. 28. — DIAGRAM SHOWING TIME OF ERUPTION OF 
THE MII<K TEETH. (CHAPIN.) 

Six to eight months after birth the two lower central in- 
cisors should make their appearance ; the upper central in- 
cisors are usually a month later. The upper lateral incisors 
are the next in order, and at the end of a year the upper an- 
terior molars should appear. At the fourteenth month the 
lower lateral incisors erupt, followed by the lower anterior 
molars. 

The canine teeth appear between the sixteenth and twenti- 
eth months, and at the end of the second year the posterior 
molars are added to complete the set. 



DISEASES OF THE MOUTH. 125 

Soon after the eruption of the milk teeth absorption begins, 
commencing at the apex of the root and extending to the 
crown, so that they are either lost by an accidental tearing of 
the membranous attachment to the gums, or are displaced by 
the advancing permanent teeth. 

Dentition is a purely physiological process, and should 
therefore run a normal, uneventful course. This is, however, 
unfortunately not always the case, and those who deny the 
possibility of a pathological condition arising from difficult 
or abnormal dentition do so simply from an unwillingness to 
recognize the relation between cause and effect so manifest in 
these cases. It is true much harm has been done by the lazy 
routine of attributing every ailment of infancy to "teething," 
or, finding the child in the act of cutting a tooth, neglecting 
to investigate further into the case, whereby many a pneu- 
monia, meningitis, gastro-enteritis or other serious condition 
has been overlooked, and another child sent "over the hill to 
the cemetery." But, notwithstanding all this, teething is re- 
sponsible for many disturbances, either directly or indirectly. 
It is hardly necessary to refer to the swollen, sensitive gums, 
the salivation, anorexia, irritability and slight fever, especially 
when several teeth are making their appearance at the same 
time, and when the gums are abnormally tough. Although 
lancing of the gums is to be condemned generally, still when 
the cusps of the molars are distinctly advanced beneath the 
mucous membrane and only delayed in making their appear- 
ance by the resisting state of the same, the use of the lance 
is imperative and will give immediate relief. 

The disturbances induced are mostly reflex, although the 
changes occurring in the shape of the lower jaw have a 
direct influence upon the floor of the middle ear. Through 
the chorda tympani nerve the buccal cavity is brought into 
close communication with the faucial extremity of the 
Eustachian tube and the middle ear. Cooper ( C linical 
Lectures Upon Inflammations of the Middle Ear) remarks 
upon the frequency with which children develop a discharge 



126 DISEASES OF CHILDREN. 

from the ear every time they cut a tooth. A common 
cause for an attack of otitis occurring during teething is ex- 
tension of the inflammatory process in the mouth, i. e., the 
catarrhal stomatitis, into the Eustachian tube to the middle 
ear, through continuity of structure. 

A later event to be encountered is the decay of the teeth. 
The relationship of enlarged tonsils, cervical adenitis, dys- 
pepsia, and other affections to carious teeth, is too well estab- 
lished to merit special discussion. It is also important that 
the milk teeth be preserved as long as possible, for their pre- 
mature loss interferes with the full growth and proper de- 
velopment of the jaw, thereby inviting a contracted palate, 
abnormally small jaw or irregularities in the permanent 
teeth. 

Treatment. — The hygiene of the mouth is of prime im- 
portance in preventing and ameliorating the local manifesta- 
tions. Cleansing the gums with a soft linen cloth dipped in 
plain cold water is beneficial when they are hot and swollen. 
An occasional drink of cold water will serve the double pur- 
pose of cooling the gums when there is gingivitis and mitigat- 
ing the febrile phenomena. One of the following remedies will 
be found efficient in meeting the local and general symptoms : 

Bell, and Cham, are perhaps the most frequently employed 
remedies in teething disturbances, Chamomilla being indi- 
cated by the irritable temper, the greenish, offensive diar- 
rhoea, and circumscribed redness of the cheeks, and Bella- 
donna when there is cerebral hyperemia, high fever, and 
tendency to convulsions. The gums are red and swollen. 

Ferrum phos. is especially useful when the respiratory tract 
becomes involved, indicated by rapid breathing, hard, dry- 
cough, hoarseness, great restlessness. Aeon, is similar, but 
there is more nervous erethism and vascular excitement. 

Terebinthina. This remedy was first recommended by 
Cooper, and it has proven of value in my hands. When there 
is great restlessness at night ; interstitial distention of the 
gums ; symptoms of intestinal irritation, such as starting and 



DISEASES OF THE MOUTH. 127 

twitching during sleep, gritting of the teeth and picking the 
nose, Terebinthina is strongly indicated and acts promptly. 

The Calcareas are very useful, especially as constitutional 
remedies. The Carbonate is indicated in children teething 
rapidly, and follows well after Belladonna in acute conditions. 
The Phosphate is more suited to emaciated or rachitic infants 
with open fontanelles, delayed dentition and tendency to early 
decay of the teeth. 

ABNORMALITIES OF THE TEETH. 

The most characteristic deformity seen in the teeth is the 
condition first described by Hutchinson. As a result of con- 
genital syphilis, a lack of development in the permanent teeth 
takes place, and, the enamel being deficient upon the cutting 




FIG. 29. — HUTCHINSON TEETH. THE UPPER INCISORS SHOW- 
INCOMPLETE NOTCHES. THEY DIVERGE, LEAVING A 
WIDE INTER-SPACE. AFTER HUTCHINSON. 
(BARTLETT'S DIAGNOSIS.) 

surface of the upper central incisors, a semilunar notch is 
worn into them (Fig. 29). These teeth are shorter than normal 
and their sides somewhat sloping, giving them the form of a 
screwdriver, being narrower at their cutting edge than at the 
root. Besides, the canine teeth are rudimentary and peg- 
shaped. This combination of abnormal teeth is named after 
Hutchinson and considered pathognomonic of congenital syph- 
ilis, although not commonly encountered, even in syphilitic 
children. 

The milk teeth are not characteristically affected by syph- 
ilis; they may be poor in quality and decay early, or they 



128 DISEASES OF CHILDREN. 

may show irregularities in form and in their enamel covering. 
Any form of stomatitis, however, can affect the development 
of the teeth. 

Rickets delays the eruption of the teeth, and in such chil- 
dren they are, as a rule, abnormally soft and decay early. 
The permanent teeth may show transverse ridges or a serrated 
edge as a result of rickets or stomatitis. Any disease affect- 
ing the general nutrition naturally shows its influence upon 
the teeth if it be active at the time of their eruption. 

STOMATITIS. 

The term stomatitis is applied to the several forms of in- 
flammatory affections involving the mucous membrane of the 
buccal cavity. It is a common affection among children, and 
can be traced to various causes, each of which will be fully 
discussed under its appropriate heading. 

CATARRHAL STOMATITIS. 

This form of stomatitis presents an acute diffuse inflamma- 
tion of the mucous membrane of the mouth. 

Etiology. — The exciting cause is usually some form of local 
irritation, such as unclean nipples; improper food, or giving 
the food too hot ; infection of the mouth with various micro- 
organisms, made possible by lack of proper cleanliness. The 
predisposing factor is, in the vast majority of cases, gastro- 
intestinal derangement. Hot weather and artificial feeding 
are therefore responsible for most cases of stomatitis. The 
scrofulous diathesis, with its tendency to catarrhal inflamma- 
tions of all mucous membranes, is often present, and in such 
cases difficult dentition may be the exciting cause. It may be 
associated with the eruption of the teeth, or occur during an 
infectious disease. 

Symptomatology. — Primarily there is heat and dryness of 
the mucous membrane of the mouth and gums, together with 
redness and swelling. This is generally uniform, although it 
may be more marked in circumscribed areas. Later there is 



DISEASES OF THE MOUTH. 129 

increased secretion of mucus and saliva, which generally 
dribbles from the mouth. Pain is present, and the pathogno- 
monic symptom, "The child seizes the nipple eagerly, but 
after a few pulls at the breast drops it with a cry," is ex- 
plained by this exquisite tenderness of the mouth. The child 
is fretful and feverish, and, owing to the inability to nurse 
successfully, soon loses in weight. Diarrhoea and vomiting 
must rather be considered as concomitants of the general con- 
dition than as a direct result of the stomatitis. It is usually 
of short duration and does not terminate in ulceration. 

PITYRIASIS LINGUAE 

Is a chronic catarrhal inflammation involving the upper 
surface of the tongue, resulting in the characteristic condition 
known as linginz geographica. It begins as a circular patch 
or patches of epithelial hyperplasia forming elevated whitish 
spots, which enlarge and ultimately begin to desquamate 
in the centre, forming irregular plaques, with islands of nor- 
mal mucous membrane interspersed between the hyperplastic 
epithelium. Several of the ring-like lesions coalesce and 
form the geographical map giving the disease its name. This 
affection shows great tendency to recur, the interval between 
the disappearance of the old lesions and the reappearance of 
a new annular patch being usually of short duration. It is 
met with in children of all ages, in the healthy as well as 
sickly, although perhaps most frequently in the rachitic. 

APHTHOUS STOMATITIS. 

Aphthous stomatitis is a vesicular inflammation of the 
mucous membrane of the mouth, resulting in localized 
erosions. 

Etiology. — The etiology of this affection is not well under- 
Stood, unless it be considered as a more pronounced form of 
the catarrhal variety resulting in vesication. Forchheimer 
looks upon aphthous stomatitis as an acute infection of in- 
testinal origin and he compares it to foot and mouth dis 



130 DISEASES OF CHILDREN. 

of cattle. Filatow believes it to be a local infection, as it 
often attacks several children in one family simultaneously. 
It is most commonly seen from the first to the third year. 

Pathology. — Together with a diffuse catarrhal inflamma- 
tion there is vesicle formation, destruction of the vesicle, and 
superficial erosion resulting at the site of the vesicle. These 
erosions usually have a yellowish or dirty-grayish base con- 
sisting of a fibrinous exudate and epithelial debris. The 
lesions are surrounded by a red areola, and several may 
coalesce, forming irregular superficial erosions. They heal 
by a skinning over of the epithelium from the periphery and 
leave no scars. 

Symptomatology. — The general symptoms of stomatitis, 
together with the characteristic lesions described above, make 
up the clinical picture. There is more pain than in the 
catarrhal form. The lesions are most frequently located on 
the tongue, the inside of the lips and of the cheeks, and in 
some instances they are found on the palate and in the 
pharynx. The breath is not foul, as in ulcerative stomatitis, 
and the course is usually of short duration, although it may 
be self-prolonging by the interference with nutrition. 

bednar's aphtha. 

This is a condition which must be distinguished from 
aphthous stomatitis, being only found in children between 
the ages of two days and six weeks, characterized by the for- 
mation of a round, superficial ulcer, one situated at each 
angle of the palate. The pj-ognosis is usually favorable in 
this disease, although deep ulceration of the tissues has been 
observed. It is no doubt brought on by traumatism from the 
nipple or nurse's finger in washing the mouth. 

APHTHA EPIZOOTICS. 

This is an infectious form of vesicular stomatitis, resulting 
from the use of unsterilized milk from cows affected with the 
disease. There is more fever than in aphthous stomatitis, 



DISEASES OF THE MOUTH. 131 

salivation and coryza accompany the other symptoms, and the 
vesicles do not appear on the dorsum of the tongue or 
pharynx, but are usually situated on the soft palate, lips, 
gums and cheeks. There is also foetid breath, sometimes 
vomiting and diarrhoea. It runs its course in from one to 
two weeks. 

In varicella vesicles often appear in the mouth, but they 
seldom break down, and the cutaneous manifestations are 
sufficient to differentiate it from aphthous stomatitis. 

ULCERATIVE STOMATITIS ; PUTRID SORE MOUTH. 

This variety presents an inflammation of the mucous mem- 
brane of the mouth, accompanied by ulceration. 

Etiology. — The destructive inflammation of ulcerative 
stomatitis is due to a local infection. Although it has oc- 
curred epidemically, no specific micro-organism has been 
demonstrated, and it seems that the ordinary pyogenic bacteria 
will induce the disease when they find a soil favorable to 
their propagation. We can, therefore, understand how lack 
of proper cleanliness of the month and an enfeebled consti- 
tution, with unhygienic surroundings and improper nourish- 
ment — perhaps a scorbutic state — will invite the outbreak of 
an attack of ulcerative stomatitis. It may also result from 
the abuse of the metallic drugs, notably Mercury, and never 
develops until dentition is well established. 

Pathology. — The morbid process begins with an inflamma- 
tion of the anterior border of the gums, at the roots of the 
teeth, most frequently on the lower jaw. Redness and swell- 
ing are the initial changes, after which a yellow line, indicat- 
ing the beginning of the necrotic process, develops along the 
alveolar border and extends downwards. From the gums the 
process extends to the inner margin of the lips, and large 
ulcers are generally formed on the lining of the cheeks op- 
posite to the molar teeth. The sides of the tongue frequently 
participate, becoming infected by direct contact with the 
lesions. 



132 DISEASES OF CHILDREN. 

Symptomatology. — In the beginning of the disease there 
are the usual symptoms of stomatitis, but soon the character- 
istic foul breath develops, the pain becomes intense, and 
prostration and fever is more marked than in the other forms. 
This is easily understood when we consider the severity of 
the process and the intoxication resulting from the absorption 
of the putrid material forming in the mouth. Under proper 
treatment it may be eradicated in the course of a few days, 
although the prognosis must remain guarded in frail constitu- 
tions, or where the ulceration affects the deeper structures and 
there is general systemic involvement, as indicated by a con- 
tinued high temperature ; rapid, weak pulse, and lymphatic 
enlargement. 

PARASITIC STOMATITIS; THRUSH. 

Parasitic stomatitis is an affection of the mouth due to the 
development of a parasitic fungus within the mucous mem- 
brane, and is characterized by the appearance of milk-white 
patches which are difficult to remove and have a tendency to 
coalesce and spread extensively. 

Etiology. — The saccharomyces albicans, a fungus of the 
group saccharomyces, is found in the mucous membrane 
wherever the lesions develop. If a portion of the white pel- 
licle be removed and placed on a slide with a drop of liquor 
potassse the mycelium and the spores can be readily made out. 
Plaut considers the ordinary mould fungus as the etiological 
factor. 

Artificial feeding by careless methods, early life, exhaust- 
ing diseases, catarrhal stomatitis, insufficient salivary secre- 
tion, unsanitary surroundings and lack of proper care are all 
prominent etiological factors. The disease can be communi- 
cated directly from one patient to another, and is quite com- 
mon in foundling asylums and among the poorer classes. 

Pathology. — The spores of the saccharomyces albicans, 
finding their way into the mouth of the infant, soon develop 
their mycelia, which penetrate the layers of the mucous 



DISEASES OF THE MOUTH. 133 

membrane and form the white patches or elevations so char- 
acteristic of the affection. These patches are difficult to re- 
move, as they are within the mucous membrane, but there is 
no exudation or pus formation accompanying the process. 
The lesions usually begin as small white points on the inner 
surface of the cheeks, quickly spread and coalesce, so that in 
a short time the entire buccal cavity and pharynx may be in- 
volved. Extension to the oesophagus is rare, and to the 
stomach still rarer, as it confines itself almost exclusively to the 
squamous epithelium. Rare cases, however, are on record in 
which these localities were affected, beside the lower rectum, 
the female genitalia, the upper respiratory tract, intestines, 
and abraded cutaneous surfaces. 

Preceding the outbreak of thrush the mucous membrane of 
the mouth is hot and dry ; later there is a sticky mucous secre- 
tion, acid in reaction. This is partly due to a lack of the nor- 
mal alkaline salivary secretion, and to saccharine fermentation, 
the result of the growth of the fungus. 

Symptomatology. — Beside the objective symptoms already 
described there is generally a painful condition of the mouth, 
due to the catarrhal stomatitis set up by the fungus. Thrush 
being seldom a primary affection, as a rule developing during 
the course of some acute gastro-intestinal disorder or a more 
chronic exhaustive disease, it cannot be said to have many 
symptoms of its own, excepting the objective manifestations. 
The prognosis^ therefore, depends upon the accompanying 
condition, and ordinarily it is very favorable ; but in an en- 
feebled constitution the development of thrush is a most un- 
favorable sign, running a very stubborn course or indicating 
the hopelessness of the case. 

Diagnosis. — The white pellicle of thrush closely resembles 
flakes of coagulated milk and. in the beginning is often mis- 
taken for such; but the difficulty with which these spots can 
be removed and the associated stomatitis readily differentiates 
it from such a condition. Thrush has been mistaken for diph- 
theritic deposit, but here the age of the patient, together with 



134 DISEASES OF CHILDREN. 

the associated conditions, the absence of foul breath, glandular 
involvement, fever and prostration, and the superficial char- 
acter of the lesions, should readily differentiate the two. 
Where doubt exists, the microscope should be resorted to. 

GANGRENOUS STOMATITIS — NOMA. 

A destructive inflammatory process involving usually the 
cheeks and developing secondarily to one of the exanthemata 
or to some exhausting disease. 

Etiology. — It generally follows upon measles, scarlet fever, 
typhoid fever, or some form of exhausting disease, occurring 
most frequently between the age of three and six years and 
in the poorer classes. The pyogenic bacteria, notably the 
streptococcus pyogenes, are responsible for the destructive 
pathological changes. In a certain number of cases the diph- 
theria bacillus was present (Walsh). 

Pathology. — Beginning on the inside of the cheek or near 
the corner of the mouth, a small vesicle, filled with a turbid 
fluid, is formed. The vesicle breaks and leaves a superficial 
ulcer with a hard, infiltrated base, which can be felt through 
the cheek. This breaks down* and a rapidly spreading gan- 
grenous process develops, with no tendency to limitation. 
The affected parts become infiltrated and cedematous. present- 
ing a shiny, livid appearance. 

Symptomatology. — Often the first symptom noticed will be 
the ulcer, as the vesicle is easily overlooked. The breath is 
foul, prostration profound, and the temperature of the septic- 
fever type. The prognosis is unfavorable, the patient either 
succumbing to septicaemia or to a secondary broncho-pneu- 
monia; fatal haemorrhage is rare. In the case of recovery 
there is usually marked deformity. 

Treatment of Stomatitis. — All forms of stomatitis can, to a 
great measure, be prevented by strict attention to the hygiene 
of the mouth, as well as careful supervision of the diet and 
general hygiene of the child. With artificially-fed babies, it 
is important to have the nipples and bottles kept perfectly 



DISEASES OF THE MOUTH. 135 

clean and sterilized (see "Care of the Mouth," Chapter I). 
During the course of an acute illness, especially one of the 
infectious fevers, it is imperative to have the mouth kept in 
a perfectly clean and sweet condition, for it is in these cases 
that noma is liable to develop, particularly in the enfeebled 
and poorly nourished. 

In the case of very young infants at the breast it is safer to 
wash the nipple with a Boric acid solution than to attempt to 
clean the babe's mouth. An injury to the mucous membrane 
is easily produced, which will act as the starting point of an 
infection. 

Should stomatitis develop, a mild antiseptic wash will be 
sufficient to carry the case through, excepting in the gan- 
grenous form, which is, strictly speaking, a surgical disease. 
For this purpose, either a 4 per cent. Boric acid solution, 
alcohol diluted with three parts water, or, in the ulcerative 
form, Hydrogen dioxide, one part to four of water, will be the 
least harmful and most serviceable antiseptic. In stubborn 
cases of thrush it may become necessary to touch the patches 
carefully with a 2 per cent, solution of Silver nitrate ; this is 
to be followed by rinsing the mouth with salt water. 

The diet is important in ulcerative stomatitis. By a re- 
striction in the use of all salty articles of food, and the free 
use of fruit juices and vegetable broths, these cases recover 
more promptly than under ordinary treatment. Owing to the 
painful condition of the mouth the diet should be restricted 
to liquids and semi-solids, and in older children the use of a 
tube or feeding-cup with a spout will be very grateful. 

Borax is perhaps the most useful remedy in the aphthous 
and parasitic form, especially in the early stages, with heat 
and dryness of the mouth. It may be applied directly to the 
affected parts either in pure form or in the first decimal 
trituration, which, being slightly sweet, is more pleasant to 
the child, 01 it may be used in the form of a saturated solu- 
tion. The internal administration of Borax is also advan- 
tageous. The symptoms on which it is prescribed arc : 



136 DISEASES OF CHILDREN. 

Aphthae ; vomiting ; flatulent distention of abdomen ; loose, 
yellowish, slimy stools ; greenish stools preceded by crying. 
Child cries out as if frightened during sleep. 

Mercurius may be indicated in all forms, but pathologically 
it corresponds most closely to the ulcerative form. Personally 
I have obtained the best results from Baptisia in this variety, 
as the sphere of usefulness of Mercury seems limited to 
syphilitic cases. Merc. corr. 3X trit. is useful in bad cases of 
thrush. Hepar is the remedy for mercurial stomatitis. 
Chlorate of Potash in small doses is indicated in herpetic and 
aphthous stomatitis. Other remedies which may prove 
useful are : 

Arum triph. — Aphthse ; lips swollen. 

ALthusa. — Thrush ; vomiting of large curds. 

Ars. — Thrush ; exhausting diseases ; prostration ; dryness 
of mouth. 

Baptisia. — Ulcerative stomatitis ; great fetor of breath ; 
offensive diarrhoea ; typhoid state. Also useful in mercurial 
stomatitis. 

Bry. — Catarrhal stomatitis ; great dryness of mouth. 

Hydrastis. — Superficial ulceration ; tenacious mucus. 

Natr. mur. — Gums spongy ; superficial ulcers on tongue 
and cheeks. 

Nitr. ac. — Ulcerative stomatitis; after Merairy ; fetid 
breath and acrid saliva ; acrid diarrhoea ; cracking of the 
corners of the mouth. 

Rhus tox. — Great restlessness ; saliva bloody ; lips cracked. 

Sulphur.— Ulcerative stomatitis ; gums swollen and reced- 
ing ; marasmus. Bright redness of lips. 



CHAPTER VII. 

DISEASES OF THE STOMACH. 

The investigation of the diseases of the stomach in infants 
is based upon practically the same principles underlying this 
special department of clinical medicine in adults. Owing, 
however, to both anatomical and physiological differences, 
and I might add psychic, a slight divergence in methods 
must necessarily exist, the appreciation of which becomes of 
the most practical importance. 

There are a number of nervous gastric disturbances — gastric 
neuroses — common in adults and, on the other hand, practi- 
cally unknown in infancy. I refer to hyperchlorrhydria, idio- 
pathic achylia gastrica, gastralgia, nausea and dyspepsia ner- 
vosa. This class represents states of sensory, motor and secre- 
tory irritation or depression and originates in causes not yet 
operating in infancy. 

Again, malignant disease may practically be discarded from 
the category of gastric diseases in infants. Isolated cases have 
been reported, but the majority of these were never suspected 
during life. 

The chief etiological factor in gastric disturbances in in- 
fants is improper feeding. This is a complex factor which 
may be analyzed into (a) the use of foods of improper compo- 
sition ; (b) the administration of abnormally large quantities 
of food; if) irregularity in the time of feeding, and (d) im- 
proper temperature of the food. A last factor, so important 
that it merits separate discussion, is infection. The micro- 
organisms setting up pathological changes in the gastric 
mucosa almost invariably gain access to the system with the 
food. The prevention of such an infection is therefore en- 
tirely within our control. 

The toxins generated by these micro-organisms act either 
10 



138 DISEASES OF CHILDREN. 

directly upon the mucous membrane or fermentative changes 
are induced in the chyme with the liberation of irritating 
products. Accordingly, bacterial contamination of the food 
is responsible for the occurrence of cholera infantum, ileo- 
colitis, acute and subacute gastritis, and many cases of acute 
indigestion. The derangements resulting from improper 
foods are acute and chronic indigestion, gastric catarrh, gas- 
tric dilatation, colic and vomiting. Colic is a distressing 
symptom common in infants and is often gastric in origin. 
It is most often due to flatulency, although I am positive that 
a large number of cases depend upon the presence of tenacious 
mucus in the stomach, which acts by interfering with diges- 
tion and with the exit of the food through the pylorus. 

Colic may also result from taking the food too rapidly, in 
too large quantities, and from excess of proteids. Again, 
some cases seem to depend upon an inability to digest fat in 
normal and even decreased percentage, owing to a gastro- 
intestinal catarrh. 

An important fact that cannot be disregarded is the impos- 
sibility of drawing a sharp line of demarcation between dis- 
eases of the stomach and intestines. In adults there is greater 
possibility of doing this. The infantile stomach is nothing 
more than a dilatation of the alimentary canal and is not com- 
pletely diffeientiated from the same. Its position at first is 
almost vertical ; its capacity is relatively small and its sphinc- 
ters are immature. Physiologically it is also immature, the 
main work of digestion falling upon the intestinal tract. 
Under normal conditions, therefore, the food (breast-milk) is 
coagulated shortly after reaching the stomach by the rennin 
of the gastric juice. Hydrochloric acid is now secreted and 
the casein is converted into acid albumin (syntonin). The 
action of the pepsin simultaneously secreted is feeble. In 
fact, the food does not remain long enough in the stomach to 
be digested very completely. In a long ' series of cases that I 
have studied very critically I have found that in infants under 
six months there is rarelv a trace of food in the stomach at 



DISEASES OF THE STOMACH. 139 

the end of an hour under normal circumstances. In fact, at 
any period of infancy the stomach should have emptied itself 
at the end of two hours. If gastric contents can be recovered 
after that time, we are confronted with an abnormal condition. 

The various steps in the examination of the stomach are — 

Inspection. — In an emaciated infant it is possible to see the 
outline of the lower border of the stomach when the same is 
distended. It is impossible to arbitrarily decide just where 
this should reach, because the stomach may undergo a certain 
amount of distension under normal conditions, and its size 
also varies in different individuals. A safe rule, however, to 
follow is to look upon any stomach as dilated that reaches 
below the umbilicus, unless there be an enteroptosis. The 
latter condition I have never encountered in an infant. 
Again, when the stomach is dilated its outline is abnormally 
large; the transverse position is exaggerated, the cardiac ex- 
tremity showing the greatest amount of enlargement. Irreg- 
ular or saccular dilatation is exceedingly rare. 

A condition from which dilatation of the stomach must be 
differentiated is dilatation of the colon. The latter, however, 
presents a concave outline, while the lower border of the 
stomach is convex. 

In pyloric obstruction, peristaltic waves beginning at the 
cardia and traveling toward the pylorus may be seen. Py- 
loric obstruction may be congenital or acquired. Some cases 
appear to be spasmodic in character. In typical cases the 
pyloric extremity of the stomach is found to be hypertrophied 
and sclerotic in nature at the autopsy. I believe a certain 
amount of pyloric obstruction not infrequently accompanies 
gastric catarrh, and I have been able to control the condition 
with systematically conducted lavage in a number of cases. 
Again, I have observed hyperacidity of the gastric contents 
in a few cases with gastric dilatation, presumably not due to 
over-feeding. It is fair to infer that spasm of the pylorus 
may result in these cases from irritation by the hyperacid 
gastric contents; it will require further investigation, how- 
ever, to prove this assertion. 



140 DISEASES OF CHILDREN. 

Percussion. — This is a most valuable aid in determining 
the size of the stomach. The best results are achieved by 
filling the stomach with water through a lavage apparatus 
and outlining the absolute dullness obtained in this way. I 
do not look upon this as a dangerous procedure when the 
child is placed in the prone position and the water poured in 
slowly, from only a moderate height (one to two feet). 

Traube's semilunar space is not as sharply outlined in in- 
fants as in adults, owing to the vertical position of the 
stomach and the horizontal position of the ribs. It is diffi- 
cult to elicit and throws no light on the present subjects. 

Mensuration. — I will apply the term mensuration in the 
sense of estimating the capacity of the stomach. This can be 
done by pouring water into the stomach through a lavage ap- 
paratus from a graduate and noting the amount required to 
fill the stomach. If carried out as above specified there will 
be no danger of doing harm. The stomach of the new-born 
holds about one ounce, and its capacity increases at the rate 
of one ounce per month, so that a two months infant will 
have a capacity of three ounces ; a three months infant, four 
ounces ; four months, five ounces ; five months, six ounces ; 
six to eight months, seven ounces; eight to ten months, 
eight ounces ; one year, nine ounces. 

At the same time we can outline the stomach. These data 
give positive indications as to whether the stomach is normal 
or dilated. Another point, namely, the length of time the 
food remains in the stomach, also bears a strong relation to 
dilatation of the stomach. This will be discussed further on. 

Auscultation. — Stenosis of the cardiac orifice is indicated 
by absence of the deglutition sound over the stomach. In 
dilatation splashing sounds are readily elicited by tapping 
against the stomach walls and setting in motion the gastric 
contents. As a means of outlining the stomach the stroking 
method with the phonendoscope is a very convenient pro- 
cedure. The stem of the instrument is placed over the 
stomach just to the left of the median line in the epigastric 



DISEASES OF THE STOMACH. 141 

region, midway between the ensiforrn cartilage and the um- 
bilicus, and with the ringer light strokes are made in different 
directions radiating toward the stem of the instrument. It is 
best to use only one ear piece in carrying out this method. As 
the finger passes over the border of the stomach a change in 
the sound is perceived. The points where this change takes 
place are marked and in this way the outline of the organ — at 
least of the cardiac extremity — is obtained. 

Palpation. — Palpation is more applicable to the other ab- 
dominal organs than to the stomach. New growths are ex- 
ceedingly rare and pyloric hypertrophy is not always suffi- 
ciently marked to become palpable, but it may at times be 
determined. Points of tenderness, may be elicited by palpa- 
tion ; and we must not lose sight of the fact that ulcer of the 
stomach may be present at an early period. 

The interpretation of the symptoms referred to the stomach 
is an important point in diagnosing. 

Vomiting. — Persistent vomiting from birth indicates either 
cardiac or pyloric obstruction. In the former deglutition 
sounds are absent, w T hile in the latter the food is generally re- 
tained abnormally long before being rejected. At the same 
time dilatation of the stomach develops together with other 
signs of pyloric obstruction. 

The natural tendency for infants to vomit must not be lost 
sight of. The cardiac sphincter is poorly developed and 
owing to the habit of gulping the food too rapidly or over- 
filling the stomach, vomiting is a common symptom. When 
the milk is too rich in fat it regurgitates shortly after nursing 
without being curdled. In indigestion the food is usually 
vomited an hour or more after nursing and it is curdled and 
sour. In acute gastritis there is fever ; the food is promptly 
rejected and mucus is present in the vomit. In pyloric ob- 
struction vomiting takes place after the stomach has become 
overfilled. The vomiting of intestinal obstruction is forceful 
and persistent ; at first, gastric contents are rejected and later 
foecal matter appears. The vomiting of brain disease {reflex 



142 DISEASES OF CHILDREN. 

vomiting) is projectile and unassociated with any gastric de- 
rangement. It is not easily differentiated from ordinary in- 
fantile vomiting. Cyclic vomiting is periodic ; it occurs in 
older children and is due to auto-intoxication. The vomit 
often contains acetone and diacetic acid. 

Pain. — Gastric pain in infants is usually spoken of as colic, 
although colic is perhaps more frequently intestinal than gas- 
tric. Gastric pain has been referred to above. Its true na- 
ture cannot be determined until the case has been investigated 
in every detail. 

The final step comprises the chemical examination of the 
gastric contents. 

The gastric contents are recovered by means of a soft rubber 
catheter into the free end of which a piece of glass tubing 
about three inches long should be inserted. For an infant 
three months old I use a number ten (English), from the 
third to the sixth months a number eleven, and from six 
months up a number twelve. It is well to slightly enlarge 
the eye of the catheter in order to permit the chyme to escape 
more readily. As soon as the tip of the catheter reaches the 
fundus of the stomach the chyme, as a rule, flows out freely 
if the stomach be full. Should there be difficulty in obtain- 
ing a specimen, the child may be bent forward and gentle 
pressure made over the. pit of the stomach. This failing, it is 
better to withdraw the catheter and clean it in case it has be- 
come clogged with mucus or curds, then reintroduce and 
make another attempt. I do not approve of using suction, as 
I have seen it bring blood even when cautiously employed. 
By this means we obtain a specimen of the gastric contents 
for inspection, and can judge of the state of the digestion and 
whether mucus and blood be present. We also determine 
how long the food remains in the stomach. Ordinarily the 
infant's stomach is practically empty after one hour ; in 
young infants it may be empty three-fourths of an hour after 
nursing, and under all conditions it should be empty after 
two hours in an infant one year old. In pronounced cases of 



DISEASES OF THE STOMACH. 143 

dilatation and atony the entire amount that was taken may 
be recovered after two hours. 

The coagulated state of the milk indicates the presence of 
rennin. Mucus in small quantities may be normally present, 
but excessive amounts of thick tenacious mucus always stand 
for gastric catarrh. Blood not infrequently appears in the 
gastric contents, and, contrary 7 to what may be expected, it 
rarely signifies ulceration. This is especially so of bright 
blood, which, in the majority of instances, originates from 
capillary oozing from the mucous membrane. In aphthous 
ulceration of the stomach the blood is usually dark in color. 

The odor is also important to note. Butyric acid and 
acetone are detected by their odor. Fermentation may also 
be detected in cases fed on malt foods. 

In order to estimate the amount oifree and combined hydro- 
chloric acid we must use a test-meal of barley water, as milk 
combines so energetically with HC1 that no trace of free acid 
can be detected in the chyme. In some cases we must with- 
draw the test-meal at the end of three-quarters of an hour or 
we will find the stomach entirely empty. 

The method of estimating the acidity which I personally 
follow is a simplification of the titration method. I have 
described it and my instrument in a previous article (Hahn. 
Monthly, May, 1903, A Study of the Gastric Contents in In- 
fancy). The procedure is as follows : Pour the filtered stomach 
contents into the acidometer (Fig. 30) up to the line marked "S." 
Add a drop of dimethyl-amido-azo-benzol (if free hydrochloric 
acid has been detected previously by Boas' test) and then pour 
in, drop by drop, decinormal soda solution under gentle agita- 
tion of the tube. As soon as the red color is changed to 
orange, read off the amount of soda solution that was required 
and multiply by twenty. The product represents the amount 
of free HC1 (/. <?., the number of c.c. of decinormal soda solu- 
tion necessary to neutralize the free acid in one hundred c.c. 
of stomach contents). Now add a drop of phenolplithalein 
and continue adding soda solution until a pink color is ob- 



144 



DISEASES OF CHILDREN. 



-H 



tained; read off the number of c.c. required and multiply by 
twenty ; this gives the combined acid on the same basis as 
above. The product of the sum represents the total acidity. 
The examination for free HC1 and the calculation of the total 
acidity are data of the highest importance in gastrological 
work. Regarding the total acidity in infants I have formu- 
lated the following rule : Normal, thirty to forty ; in indiges- 
tion and mild grade catarrhal con- 
ditions it ranges between fifteen to 
twenty-five, while an acidity below 
ten indicates a grave condition, 
i. £., either acute gastritis, chronic 
atrophic gastritis or marasmus. In 
the newborn — ten days old — I have 
found the acidity to be ten, pretty 
constantly. It gradually rises as the 
infant grows older. 

Lactic Acid. — It is claimed that 
lactic acid is found normally in the 
stomach in the early stages of diges- 
tion. Under these circumstances the 
V / 1 1 amount is exceedingly small. Lactic 

^7 C"^\ \/ ac id that can be demonstrated in the 

^ — ^^ gastric contents by Uffelmann's test 

is always abnormal. As hydrochloric 
acid inhibits lactic acid fermenta- 
tion, the two. practically never occur 
together. Of course, it is sometimes 
possible to demonstrate a trace of lactic acid at the very close 
of digestion when a milk diet has been used and the stomach 
is almost empty, as under these circumstances the secretion of 
HC1 has ceased, or it has all combined with the casein, and a 
trifling amount of lactic acid fermentation may take place. 
This is seen in infants with dilatation and atony. In cases 
of gastritis, gastric catarrh and marasmus, where hydrochloric 
acid is absent, lactic acid is invariably found when milk or a 



FIG. 30. — AUTHOR'S ACIDO- 

METER FOR ESTIMATING 

THE ACIDITY OF THE 

GASTRIC CONTENTS. 



DISEASES OF THE STOMACH. 145 

food containing lactose has been administered. The invari- 
able absence of hydrochloric acid in marasmus is a fact I 
have been able to prove conclusively after a thorough investi- 
gation of the subject. For a more detailed discussion I must 
refer to the article mentioned above. 

Uffelmann's reagent consists of a weak, watery solution of 
neutral ferrous chlorid to which a few drops of a 5 per cent, 
solution carbolic acid have been added. This imparts to the 
reagent a steel color. Lactic acid changes the reagent to a 
canary-yellow color, while HC1 only decolorizes it. Piatt 
makes the test by simply diluting the ferrous chlorid with 
water to a point where only a trace of color remains; the 
same reaction is produced in this reagent by lactic acid. 

Ptyalin. — In order to demonstrate the presence of ptyalin 
the infant should be slowly fed on an amylaceous liquid (bar- 
ley water) and the stomach contents withdrawn after half an 
hour. It is then filtered and a few drops of a weak solution 
of iodin added. If only a blue color is obtained, ptyalin is 
absent; if, however, the solution assumes a pink or an orange 
color, starch digestion is taking place. 

Pepsin. — I have repeatedly made the test for pepsin and 
have found it either absent or very feeble. It is done as fol- 
lows: Place clean cut pieces of boiled white of egg into the 
gastric contents and acidulate with HC1 if no free acid is 
present. The tube containing the test should be kept in 
warm water at 95 to ioo° F. for several hours. If pepsin be 
present, the albumen gives evidence of being digested. The 
solution may also be tested for peptone (first boil- to exclude 
albumen and then precipitate with picric acid) 

Absorption and Motility. — The amount of food recovered 
at the end of one hour gives a clue to the motility of the 
stomach and its absorptive power. This method is more 
practical than the salol test. For testing gastric absorption a 
small amount of iodid of potash in solution may be poured 
into the stomach through a tube. The saliva is then tested 
with starch paper at intervals to note the time required to 
detect iodine in the same. 



146 DISEASES OF CHILDREN. 

ACUTE GASTRIC INDIGESTION ; DYSPEPSIA. 

An attack of indigestion in an infant or in a young child may 
induce beside the symptoms referable to the stomach others 
of quite an alarming character. If their true nature be not 
interpreted a serious error in diagnosis may result. Ordi- 
narily, there is only the general discomfort, nausea and vom- 
iting caused by the presence of undigested food in the stom- 
ach that may appear at any age, but under certain conditions, 
which no doubt depend upon bacterial activity in the gastric 
contents, the evidences of an acute intoxication are added. In 
such cases general convulsions frequently set in. The tem- 
perature may run high and remain so for several hours ; 
periodic attacks of this nature are often mistaken for malaria. 

Vomiting as a rule gives speedy relief, but even after free 
emesis fever may develop and the evidences of an acute gas- 
tritis set in, or if the stomach has not been completely 
emptied, intestinal disturbances may be added. 

Etiology. — An attack of indigestion during early infancy 
is easily explained. The stomach has feeble digestive pow- 
ers, and is very intolerant to any form of irritation. If food 
be taken in larger quantity or in more concentrated form than 
the stomach can manage, it will not be digested ; irregularity 
in feeding, especially too frequent feeding, is also a prolific 
cause of indigestion. If the food contains micro-organisms 
it will decompose shortly after entering the stomach, with 
the formation of gases, acids, and in extreme cases toxines. 

Saliva is not secreted in appreciable quantity during early 
infancy, nor is its power to convert starch into sugar devel- 
oped until after the third month ; for this reason amylaceous 
food is very prone to induce indigestion. Saccharine food, 
owing to its liability to fermentation, generally brings on 
an attack of flatulent dyspepsia when administered in excess. 

In older children the same exciting causes active in adults 
are frequently found. Irregularity in eating is a most prolific 
cause of indigestion in children, and as they are very likely to 



DISEASES OF THE STOMACH. 147 

overeat, they frequently suffer with such attacks. Chilling 
the stomach with ice-water and ice-cream, and indulging in 
indigestible substances like nuts, fruit-cake, cheese, etc., 
are very prone to induce the painful form of indigestion, 
while fats and pastry rather induce nausea and vomiting, 
and candies and cakes the flatulent type. 

Symptomatology. — In infants the first symptoms that will 
attract our attention are restlessness, crying and vomiting. 
The vomited matter consists of curds, undigested or partially 
digested food, as the case may be, and is usually mixed with 
serous fluid and acid mucus. The acidity is mainly due to 
the presence of lactic acid, as free hydrochloric acid is rare 
during infancy. 

Should the stomach not empty itself completely, severe 
constitutional symptoms will occur from the absorption of 
albumoses and products of decomposition. The child develops 
a high fever, becomes apathetic and prostrated ; the tongue 
becomes coated, the epigastrium bloated, and diarrhoea super- 
venes. This condition is frequently preceded by general 
convulsions. 

Older children are usually feverish, complain of headache, 
nausea, and more or less gastric pain, while the advent of free 
emesis is followed by decided relief. The food sometimes re- 
mains for hours in the stomach in a partially digested, decom- 
posing condition. 

A mild attack of indigestion may subside spontaneously 
after the stomach has been relieved of its contents either by 
vomiting or fasting ; but a more pronounced attack may be 
the exciting cause for an acute gastritis that may require con- 
siderable after-treatment. 

Treatment. — Prophylaxis consists in feeding the infant on 
a pasteurized modified milk containing the proper percentage 
of proteids, fat, and lactose according to the requirements and 
digestive ability of the case, given in the proper quantity and 
at regular intervals. If these conditions are carried out the 
infant will rarely suffer from indigestion (see Chap. IV, 
" Infant Feeding"). 



148 DISEASES OF CHILDREN. 

Starchy foods, excepting the cereal-water diluents, should 
never be given to a child before the eruption of the teeth has 
taken place, and then only cautiously until the molars have 
made their appearance. 

The first step in treating a case of acute indigestion is to 
empty the stomach. Sometimes it is but necessary to allow 
the infant to take several draughts of warm water, but the 
most satisfactory method is lavage. (See p. 24.) The pro- 
cess should be continued until the water comes out perfectly 
clear, and. all traces of food and mucus have been removed 
from the" stomach. In acute conditions one washing usually 
suffices. 

The stomach should now receive a rest for several hours 
and feeding be resumed cautiously, beginning with a cereal 
water. In the course of twelve to twenty-four hours if the 
symptoms have subsided milk may be cautiously added, be- 
ginning with low percentages of fat and proteids. Heubner 
uses a tablespoonful of rice-meal shaken up with cold water, 
and subsequently boiled with one pint of water for a quarter 
of an hour and sweetened with a few teaspoonfuls of milk 
sugar. According to Rotch, a modified milk containing less 
than 5 per cent, lactose, about 3 per cent, fat, and in extreme 
cases as low as 0.45 per cent, proteids, will have to be used 
until the digestive function of the stomach becomes normal. 
Naturally, this will not apply to many cases, and would be un- 
necessary starvation in most instances. Personally I give less 
fat and more proteids than represented in the above formula. 

In older children it is not so easy to employ lavage, and a 
simpler method, such as instructing them to drink warm 
water and then inducing vomiting reflexly by irritation of the 
fauces, is often more satisfactory. A tougue depressor passed 
far back over the base of the tongue is a good method of 
inducing vomiting. At the same time the throat can be fully 
inspected — a most important procedure in all acute illnesses 
associated with gastric symptoms. It is seldom, however, 
necessary to employ any artificial means, as children prover- 
bially vomit on the slightest provocation. 






DISEASES OF THE STOMACH. 149 

Remedies are seldom necessary in infants after the stomach 
has been emptied and the diet carefully regulated. How- 
ever, there are cases in which attacks of indigestion will re- 
cur despite the greatest care in these respects. Here a rem- 
edy is necessary to correct the underlying disturbance. In 
older children, who can relate their symptoms, we are often 
capable of averting an attack by an early prescription. 

Abies nigra. — Sensation of a hard-boiled egg in stomach. 

sEthusa. — Vomiting of large curds of milk, followed by 
great exhaustion. 

Antimon. crud. — Tongue white, heavily coated ; great nau- 
sea ; results of overeating. 

Arsenicum. — After chilling the stomach with ice-cream or 
ice-water ; nausea, prostration. 

Bell. — Throbbing headache ; strawberry tongue ; convul- 
sions. It is the best remedy for the febrile cases with irrita- 
tion of the nervous system, i. e n gastric toxcemia. 

Bry. — During summer and sultry weather ; anorexia, 
thirst, mouth dry, distress and pain in stomach, as of a load. 

Ipecac. — Nausea and vomiting, tongue usually clean ; stom- 
ach feels relaxed. 

Nux vom. — Tongue coated at base ; bitter taste ; painful 
pressure in stomach ; great desire to vomit — urges to do so ; 
ineffectual urging to stool ; headache and vertigo ; quarrel- 
some disposition ; face hot ; chilly feeling. 

Pulsatilla. — Tongue coated and dry; mouth feels pasty 
and contains thick saliva ; no thirst or appetite ; water 
tastes bitter ; nausea and faintness ; languor and feverish- 
ness ; diarrhoea. After rich food, pastry and cold food (Ars.). 
Often relieves when Arsenicum does not act. 

CHRONIC GASTRIC INDIGESTION ; NERVOUS DYSPEPSIA. 

A chronic condition of disordered digestion is seldom found 
without a definite pathological process involving the mucous 
membrane of the stomach, although there is sufficient clini- 
cal evidence that there may be a purely neurotic type of 



150 DISEASES OF CHILDREN. 

indigestion. Hyperacidity and increased secretion of the 
gastric juice ; diminished secretion of gastric juice ; sensory 
disturbances, and insufficiency of motor power of the stomach 
have all been observed as purely functional phenomena, 
although in the majority of cases a mild grade of gastritis 
accompanies these conditions, for which reason differentiation 
between the two is often impossible, the preponderance of the 
symptoms of the one condition over the other deciding the 
diagnosis. Hyperchlorrhydria, the commonest form of nerv- 
ous dyspepsia in adults, is only occasionally encountered in 
children. The majority of cases of indigestion still belong, 
as in infancy, under the category, improper feeding. 

Anaemia ; neurasthenia ; lithemia ; adenoid vegetations ; 
decayed teeth — are prominent factors in the etiology of dys- 
pepsia. No single cause, however, should be looked upon as 
final, but the child's constitution, hygienic surroundings, 
habits and food should be thoroughly looked into before a 
case can be intelligently and successfully treated. 

Symptomatology. — The motor power of the stomach is 
usually deficient, which allows the food to remain an undue 
length of time in the stomach, thus favoring fermentation 
and the production of gas, together with lactic, acetic, butyric 
and other acids. Regarding the anomalies in secretion, 
Leube found that there is either a diminution or excess in 
the acidity of the gastric juice, although dyspeptic symptoms 
are often encountered where the secretion is both normal in 
quantity and quality, and where the food could not be found 
remaining abnormally long in the stomach (neurotics). 

The subjective symptoms complained of are distress and 
uneasiness after eating ; sometimes malaise, headache, ver- 
tigo, and restless sleep may be observed. The appetite usu- 
ally becomes impaired and capricious and the belching of gas 
or the eructation of food or a sour liquid is common. Intes- 
tinal indigestion is so frequently associated, and the symp- 
toms of the one so gradually merge into those of the other, 
that a sharp line of distinction is impossible. 



DISEASES OF THE STOMACH. 151 

Hyperchlorrhydria is a neurosis in which an excessive secre- 
tion of hydrochloric acid takes place. It is encountered in 
neurasthenia, especially in those with gouty antecedents. The 
symptoms are burning and distress in the epigastrium ; sour 
eructations and often nausea and vomiting. The paroxysms 
come on several hours after eating and the symptoms are re- 
lieved by eating. Often there is continuous gnawing in the 
stomach and craving for food. 

In infantile indigestion there is almost always vomiting, 
and if the contents of the stomach be examined, stringy 
mucus, lactic acid and sometimes butyric acid will be found. 
Flatulency is also prominent, the intestines as well as the 
stomach sharing in the production of gas. These cases are 
usually described as colicky babies, for they rarely seem to 
be without pain. The treatment will be taken up in con- 
nection with "Chronic Gastritis," p. 161. 

ACUTE GASTRITIS. 

Acute gastritis may be encountered in the form of a ca- 
tarrhal, follicular or pseudo-membranous inflammation of the 
mucous membrane of the stomach. 

Etiology. — Although gastritis in one of its forms is fre- 
quently met with unexpectedly during an autopsy, we are, 
on the other hand, often disappointed by finding no definite 
lesions where the condition had been thought to exist during 
life. Causes which seem to excite gastritis in one individual 
produce nothing more than functional indigestion in another 
case. For this reason the etiological factors for indigestion 
must be looked upon as capable of also producing gastritis 
under certain circumstances, such as malnutrition, scrofula 
and rickets, unsanitary surroundings, especially dearth of 
pure air and sunshine and insufficient clothing. Among other 
causes as producing gastritis, such indefinite terms as " im- 
proper food or feeding" and u exaggerated form of indiges- 
tion" are mentioned. The majority of cases no doubt result 
from bacterial toxins or decomposed food. 



152 DISEASES OF CHILDREN. 

Micro-organisms do not propagate in the stomach as well 
as in the intestinal tract, for which reason gastritis is less 
common than enteritis, and when present it is usually ac- 
companied by enteritis (gastro-enteritis, summer-complaint) ; 
but it is to be remembered that the most prolific cause of gas- 
tritis in infants is the absorption of toxines, which have de- 
veloped already in the food before entering the stomach. It 
may stop just short of, or develop into, cholera infantum. 

Any irritant may induce gastritis when taken in suffi- 
cient quantity ; many drugs come under this heading. Food 
given too hot has induced it ; also ice-cold foods and drinks. 

Direct infection has occurred during diphtheria and other 
infectious diseases, resulting in the membranous variety. 

Corrosive gastritis is usually the result of the accidental 
introduction of an acid or caustic into the stomach, and be- 
longs to the domain of toxicology. 

The acute infectious diseases, such as scarlatina, pneu- 
monia, typhoid fever and septic conditions, especially when 
the intestinal tract is involved, are often accompanied by gas- 
tritis. Follicular gastritis is undoubtedly of infectious origin. 
It is most frequently encountered in the newborn and in early 
infancy. 

Pathology.— The catarrhal variety is the one most fre- 
quently met with, and presents the usual signs of catarrhal 
inflammations elsewhere. The mucous membrane is hyper- 
semic and swollen ; the sub-mucosa more or less infiltrated 
with round cells and distended with serous exudate. 

Here and there injected areas, small haemorrhages and 
superficial erosions of the mucous membrane will be found. 
The mucous membrane is usually most markedly affected at 
the pyloric end and along the greater curvature. The con- 
tents of the stomach consist of undigested and partially di- 
gested food and mucus, or it may contain only thick tena- 
cious mucus and serous fluid, with an admixture of brownish, 
decolorized blood. If the stomach is distended it usually con- 
tains offensive gas. 






DISEASES OF THE STOMACH. 153 

The follicular variety is rare, is usually associated with ca- 
tarrhal gastritis, and has no specific etiology. It is character- 
ized by swelling of the solitary lymph follicles of the stomach 
with secondary softening and necrosis, resulting in small, scat- 
tered ulcers. They are seldom large enough to attract at- 
tention, and require the microscope for verification, but in 
some cases there is sufficient ulceration to induce haemorrhage 
and other symptoms of ulcer. In melena neonatorum this 
condition is found associated with similar ulcers in the gut. 

The membranous variety of gastritis is also of rare occur- 
rence, and is always secondary to some infectious disease. 
It has been observed after diphtheria, pseudo-diphtheria, 
scarlatina, variola, typhoid fever, pyaemia, and in conjunction 
with membranous colitis. The membrane is grayish-green 
in color, and is composed of fibrin, epithelium, bacteria and 
debris. The mucous membrane is thickened and eroded be- 
neath the pseudo-membrane. Pieces of the membrane are at 
times found in the vomited matter. 

Symptomatology. — When any of the pathological changes 
mentioned above have developed to an appreciable degree, the 
symptoms of an actcte febrile gastritis are the invariable result. 
The afebrile variety of gastritis is not so severe in its course, 
and must be considered a very mild grade of gastritis, or in 
some instances a subacute form of the disease ; indeed, it is 
often impossible to draw a sharp line of distinction between 
afebrile gastritis and indigestion (functional). Rotch believes 
that the majority of cases of so-called gastritis catarrhalis are 
nothing more than functional disorders. 

The early symptoms are those of acute indigestion, namely, 
coated tongue, nausea and vomiting, pain, prostration, fever- 
ishness. Vomiting is the most prominent symptom, and is 
usually stubborn. 

Booker has shown that the food may lie from four to five 

hours in the stomach in these conditions, and for this reason 

the ejecta usually consist of undigested food, beside sour 

mucus. If the vomiting persists for a long time bile eventu- 

ii 






154 DISEASES OF CHILDREN. 

ally appears, and fermentation, with the production of gases 
and consequent flatulent distension of the epigastrium, 
takes place. 1 have -often noticed when children are fed on 
artificial foods containing malt, the stomach contents will 
ferment and the odor be strongly suggestive of stale beer. 
Dilatation of the stomach is a natural result of this abnormal 
condition. 

In my series of sixty reported gastric analyses in children 
(Hahnemannian Monthly, May, 1903) there were six cases of 
primary acute gastritis. In all, hydrochloric acid was absent 
from the stomach contents, while mucus and in two blood and 
mucus was present. When milk had been taken as a food, lactic 
acid was present. One case in which considerable blood ap- 
peared in the ejecta and in which ulceration was suspected 
showed no evidence of the same at the autopsy. 

Older children complain of headache, dizziness and nausea, 
while the infant makes its discomfort known by fretfulness, 
crying and great restlessness ; the pulse is small and rapid, 
and the extremities cold. If the gastric symptoms do not 
disappear within two days diarrhoea usually sets in. 

The febrile variety is more characteristic in its course, and 
points to decided involvement of the gastric mucous membrane. 
It is sudden in onset, beginning with high fever (103 to 104 ), 
vomiting and prostration. The tongue is heavily coated and 
may show the imprints of the teeth ; the breath is offensive 
and vomiting persistent, even drinks being ejected as soon as 
they reach the stomach. In the beginning food and mucus 
constitute the vomited matter ; later, bile may appear. The 
mucus is frothy and sour, often containing blood. 

Epigastric tenderness is marked ; the child is exceedingly 
restless in the beginning from the pain and thirst, later be- 
coming prostrated ; the circulation weakens, the extremities 
become cold, and a clammy sweat breaks out on the forehead. 

Thirst is a prominent symptom, but appetite for food or 
tolerance for the same are characteristically absent. 

The fever generally falls after the second day, and ranges 



DISEASES OF THE STOMACH. 155 

between ioo° and ioi° for several days, until at the end of 
five days or a week it has regained the normal standard. In- 
testinal symptoms usually supervene in infants, and may pro- 
long the course of the disease. Hydroa frequently develop 
on the lips. 

In older children the temperature does not range so high, 
nor is there as much prostration. 

The prognosis is favorable excepting in debilitated or 
cachectic infants. The membranous variety can only be 
diagnosed when pieces of membrane are vomited. 

Diagnosis. — From simple indigestion gastritis is not easily 
differentiated in the beginning, but the presence of abundant 
mucus in the vomited matter, with at times blood ; absence 
of hydrochloric acid in the gastric contents ; tenderness over 
the stomach; the longer duration of the attack, symptoms 
continuing even after the stomach has been emptied and the 
diet regulated, beside the elevation of temperature, must lead 
us to suspect gastritis and exclude functional indigestion. 

The febrile variety is most likely to be confused with be- 
ginning typhoid fever ; however, the absence of nose-bleed 
and typical step-like rise of temperature, beside the absence 
of typhoid roseola and enlarged spleen, and the history of 
some dietetic error and presence of herpes labialis, will differ- 
entiate the two affections. 

The subacute form is most readily diagnosed by removing 
the contents of the stomach with the lavage apparatus, one to 
two hours after a test-meal of barley-water. The washings 
will contain particles of undigested casein if milk was pre- 
viously taken ; abundant mucous secretion ; lactic and fatty 
acids, but no free HC1. 

Treatment. — The non-febrile variety is to be treated in the 
same manner as indigestion, employing lavage once or twice 
daily, especially if there is much mucus and acid fermenta- 
tion, and withholding all food for a period of six to twelve 
hours, as the condition of the child may suggest. Feeding 
should be resumed cautiously, beginning with one of the 



156 DISEASES OF CHILDREN. 

preparations recommended under acute indigestion. Reme- 
dies are more necessary here than in simple indigestion. 
Older children should be put to bed, and likewise fed cau- 
tiously on well-diluted milk to which lime-water or seltzer 
can be added. Weak tea, beef- or mutton-broth, or one of 
the reliable proprietary foods are also permissible. Cracked 
ice is most useful for the thirst and dryness of the mouth, 
often controlling the vomiting. If it is not effectual in this 
respect, hot water may be sipped. 

The febrile form demands even a more strict mode of treat- 
ment ; here food is best withheld for twelve to twenty- 
four hours, and, if the child be feeble, rectal alimentation, 
alcohol sponge-baths and well-diluted brandy, must be re- 
sorted to. Cracked ice, hot water or albumin-water by the 
teaspoonful is all that should enter the stomach until the 
fever abates and the retching and pain cease. Lavage must 
be used with caution, although it is usually effectual. When 
vomiting becomes uncontrollable, the stomach should be put 
at absolute rest. High rectal enemata of normal saline solu- 
tion are most useful to control thirst and prevent suppression 
of urine and aid in the elimination of toxines from the blood. 
They are especially valuable when cerebral symptoms are 
present. 

Acon. — After exposure to cold ; great thirst and restless- 
ness ; high fever ; anguish. 

Ant. crud. — Anorexia ; tongue heavily coated, as if white- 
washed ; after Christmas and Thanksgiving dinners ; over- 
eating. 

Ant. tart. — Persistent vomiting, with tendency to collapse. 

Apis. — Epigastrium sensitive to touch ; yellowish diar- 
rhoea ; scanty urine. 

Arnica. — After overeating; belching of putrid gas, tasting 
like rotten eggs ; head hot, extremities cold. 

Arsenicum. — After ice- water, ice-cream ; great thirst, tak- 
ing little at a time ; vomits when rising ; prostration marked ; 
restlessness. 



DISEASES OF THE STOMACH. 157 

Bell. — Full, bounding pulse and high fever; coated tongue 
with prominent papillae ; thirsty, but drinking aggravates. 
Cerebral symptoms. 

Bry. — Loss of appetite ; great thirst for large quantities of 
water ; sensation of a load in stomach. 

Ferrum phos. — Inflammatory stomach-ache in children from 
chill, with diarrhoea. — (Boericke and Dewey.) - 

Cham. — Vomiting of bile ; cheeks flushed ; fretful and ir- 
ritable temperament. 

Gels. — Fever, with drowsiness ; soft pulse ; nausea and 
dizziness. 

Ipecac. — Constant nausea ; tongue clean ; after unripe 
fruit or sour things ; also after rich food (Puis, has coated 
tongue and bitter taste). 

Iris. — Great burning in mouth, oesophagus and stomach ; 
vomiting and diarrhoea, with great prostration ; the vomited 
matter is very acid ; headache over eyes. 

Merc, dulcis 2x. — "Will cure a majority of all cases in 
children." — (Hale.) This remedy I consider the most useful 
for controlling the vomiting and cleaning the tongue. 

Nux vom. — Nausea, with great desire to vomit ; vertigo ; 
frontal headache ; irritable disposition ; bowels constipated ; 
after the use of coffee, condiments or irritating medicine, 
quack nostrums, etc. 

Podophyllum. — Ejected matter very sour ; expulsive effort 
of stomach so violent that it causes the child to cry out with 
pain ; vomiting of bile tinged with blood ; diarrhoea. 

Ptjlsat. — Tongue coated white, or yellowish and dry ; no 
appetite ; loss of smell and taste ; no desire to drink, while 
the mouth is dry and contains sticky saliva ; water tastes 
bitter; nausea several hours after eating; diarrhoea; vertigo 
and chilliness ; after rich food, pies and pastry. 

Sanguinaria, — Burning in throat and stomach ; sick head- 
ache ; tongue and lips red and dry ; nausea and vomiting. 

Sepia. — Epigastrium sensitive ; urine profuse and clear, 
later scanty, with red deposit ; tongue coated, without luster; 



158 DISEASES OF CHILDREN. 

herpetic eruption on tip and along its edges ; u especially 
in children after taking cold when the weather changes." — 
(CO. R.) 

Veratr. alb. — Persistent vomiting ; cold sweat on fore- 
head ; hippocratic countenance ; coldness of extremities ; 
hsematemesis ;" nausea, worse from rising or moving ; purging. 

CHRONIC GASTRITIS — CHRONIC GASTRIC CATARRH. 

Chronic gastritis presents in its milder form many of the 
symptoms of simple functional indigestion, and as the latter 
condition is frequently accompanied by a low grade of gas- 
tritis, the two conditions are by some authors described under 
the same heading. There are, however, definite pathological 
changes which affect the mucous membrane primarily, and 
the muscular coats secondarily, in true cases of chronic gas- 
tritis, making it a separate clinical condition. 

Etiology. — In infants the most frequent cause of chronic 
gastritis is improper feeding, both as to intervals in time of 
feeding, and quantity and quality of the food. Food of an 
indigestible nature is often given continuously for a long 
period of time (such as amylaceous preparations or milk of an 
abnormally high proteid percentage) or unsterilized nuising- 
mixtures are administered, whereby the stomach becomes ir- 
ritated from the fermentation going on during digestion. 

In older children repeated attacks of acute gastritis are 
likely to assume a chronic nature, but here, also, dietetic er- 
rors are the most frequent exciting cause of the disorder. It 
is rare, however, for a healthy child to become a victim of 
chronic gastritis ; as a rule there is some predisposing consti- 
tutional disease. In adults, the use of liquors, strong condi- 
ments and spices, rich, indigestible food, and late suppers, 
together with the cares of business and the exhausting strug- 
gle for existence, often induces a pronounced gastritis in a 
person otherwise sound in body ; but healthy children, not 
being subjected to this mode of living, naturally are exempt. 
Where, however, we have tuberculosis, rickets, syphilis, organic 



DISEASES OF THE STOMACH. 159 

heart disease and nephritis, causes which would ordinarily 
remain inactive, or at the most produce simply functional dis- 
turbances, are often sufficient to bring about definite patho- 
logical changes in the stomach. In valvular disease of the 
heart and cirrhosis of the liver the passive congestion of the 
stomach eventually results in gastritis. 

Pathology. — The mucous membrane is of a pale gray color, 
covered with tenacious mucus, aud may be thickened and 
show injected areas. These changes are most pronounced at 
the pyloric end of the stomach. Microscopically, the epi- 
thelium of the tubules is found to exhibit degenerative 
changes. In the submucosa there is round-cell infiltration, 
which may invade the glandular structure, inducing atrophy 
of the tubules. The stomach is usually dilated, and in ex- 
treme cases the mucous membrane is atrophied and smooth, 
while the submucous and muscular layer are much increased 
in thickness. 

Symptomatology. — The cardinal symptoms are increased 
production of mucus, vomiting, indigestion and malnutrition. 
In infants there is always more or less involvement of the 
small intestines. Naturally in such cases malassimilation be- 
comes the most prominent symptom and the infant succumbs 
to marasmus. If the stomach be irrigated abundant mucus 
appears in the washings. 

Vomiting usually occurs some time after eating, the food 
being but partially digested. In older children it may occur 
in the morning before breakfast, as in adults, and consists of 
thick, glairy mucus. 

The process of digestion is slow, both on account of the pres- 
ence of mucus and the deficiency in hydrochloric acid, as well 
as the deficient motor power of the stomach. For this rea- 
son we will find food in the stomach four or five hours after 
eating. This invites fermentative changes with the forma- 
tion of gases and such acids as acetic, lactic and butyric, caus- 
ing eructations and heartburn. Secondarily, the production 
of these acids gives rise to intestinal irritation, as the intes- 



160 DISEASES OF CHILDREN. 

tinal juices are not adequate for the neutralization of this 
excessive acidity, and an acid diarrhoea may result ; or, if the 
acids be absorbed into the general system, all the evils of the 
acid dyscrasia will be encountered. Constipation is also 
frequently associated. 

Parrot divides the condition above described — namely, 
where gastric catarrh exists together with intestinal disturb- 
ance — into three stages, giving it the name athrepsia in severe 
cases. The first stage marks the advent of the gastric catarrh, 
with its symptoms of vomiting, colic, flatulent distention of 
the abdomen and diarrhoea. Next, progressive wasting makes 
itself manifest, followed by the stage of exhaustion. The 
child becomes dull and apathetic, the cry feeble, and death 
ensues, usually preceded by convulsions. 

Bwald ( u Diseases of the Stomach ") recognizes three clin- 
ical varieties of chronic gastritis, the distinction being mainly 
based upon the severity of the disease and the stage to which 
it has progressed. Thus, the first variety is described as 
simple chronic gastritis, in which the fasting stomach con- 
tains a small amount of thin, yellowish mucus, the hydro- 
chloric acid is diminished, and lactic and fatty acids are usu- 
ally present. 

Chronic mucous gastritis is characterized by the presence 
of a large amount of mucus and absence of hydrochloric acid. 

Atrophy of the gastric mucous membrane is the final stage 
of both forms, and here there is neither mucus nor gastric 
juice to be found. 

Other symptoms usually found in chronic gastritis are 
coated tongue, bad taste in the mouth, distress after eating, 
variable appetite, distended abdomen, constipation. The 
urine contains urates in excess, and often phosphates. 

As atrophy of the mucous membrane sets in, a condition of 
tru,e stomachic indigestion is established. Nutrition becomes 
much impaired and a high grade of anaemia develops, although 
the intestines greatly compensate for the disabled stomach in 
many instances. In pernicious anaemia complete atrophy of 
the gastric mucosa is frequently encountered. 



DISEASES OF THE STOMACH. 161 

Prognosis. — Unless associated with a serious constitutional 
dyscrasia or some incurable form of heart or kidney disease, 
chronic gastritis is curable in its early stages, and generally 
shows prompt improvement under the proper form of treat- 
ment. Nothing can be done for the stage of atrophy, but it 
is rarely met with in children, as they either recover or suc- 
cumb from athrepsia before the stage is reached. In very 
young and delicate children the prognosis is unfavorable 
unless the process can immediately be checked, as they lack 
the vitality necessary to rally from the resulting exhaustion. 

Diagnosis. — From the functional form of indigestion 
chronic gastritis is readily distinguished by examining the 
contents of the stomach. The presence of an abundance of 
mucus and undigested food four to five hours after eating and 
decreased hydrochloric acid secretion, together with coated 
tongue, vomiting of mucus and possibly the association of 
some constitutional disease or heart and kidney trouble, must 
at once exclude nervous dyspepsia. 

The different varieties of chronic gastritis are differentiated 
by chemical examination of the stomach contents, as described 
under the symptomatology. 

Tuberculous meningitis may be suspected from the presence 
of vomiting and wasting ; here, however, there is fever, irregu- 
lar pulse, bulging of the anterior fontanelles, and definite 
nervous symptoms. 

Treatment. — The treatment of chronic indigestion and 
chronic gastritis is practically carried out on the same lines. 
Prophylaxis is a most important factor. Pure air, pure water 
and a perfect condition of the skin are a necessity for all cases 
predisposed to these affections. The diet must be carefully 
supervised. In infants, the time for feeding and quantity for 
each feed must be carefully determined ; so also the sani- 
tary condition of the food — namely, it must be uncontammated 
by bacteria and be absolutely fresh. This applies not only 
to milk but includes especially fruits in the summer months. 

In infants milk should be withheld entirely until vomiting 



162 DISEASES OF CHILDREN. 

and the excessive secretion of mucus has been controlled, 
feeding the child during this time upon broths with a little 
rice or barley, thoroughly boiled. Albumen-water and raw 
meat juices are also to be fed at this stage. When milk is 
resumed it should be given in low percentages of fat and pro- 
teids ; the relation of these elements most likely to agree is 
two of fat to one of proteids. As there is proteid indigestion 
in these cases, the percentage must be cut down until the 
digestive powers become improved. 

In older children sugar and starch must be indulged in 
sparingly, as they favor fermentation. Rich food and fried 
dishes are to be avoided. Early in the treatment it is often 
wise to restrict the diet to milk ; later, soft-boiled eggs, chops, 
toast, succulent vegetables, fruit and some of the cereals, 
especially rice ; may be added.. 

Lavage is particularly serviceable, and as it can so readily 
be carried out in young children, it is one of the most im- 
portant therapeutic measures at our command. Indeed, many 
cases show immediate improvement after the first few wash- 
ings, more particularly in the subacute form, and rapidly re- 
cover when the indicated remedy and the proper diet are at 
the same time administered. 

In many instances the condition improves under constitu- 
tional treatment more promptly than by simply taking the 
stomach into consideration, as it is so frequently only the 
outcome of a general disturbance. 

The remedies recommended for chronic indigestion are 
numerous, but there are a few which have stood the test of 
time, and which should therefore be considered first in con- 
nection with the disease. 

Pepsin, the saccharated preparation, is a veiy useful pal- 
liative. 

Nux vom. is frequently indicated, especially if the patient 
has been dosed with harmful remedies. We must not forget, 
however, that Strychnine is frequently employed in these 
cases, and here it is better to begin with Pulsatilla, especially 



DISEASES OF THE STOMACH. 163 

if there is the pasty, heavily-coated tongue ; mouth dry, con- 
taining a little thick mucus ; no thirst ; distress or vomiting 
occurring an hour or more after eating ; symptoms developing 
after rich foods and pastry ; belching which gives relief ; in 
younger children usually vomiting of undigested food contain- 
ing mucus, and diarrhoea. 

A tropin sulph., 3X trit., one to two tablets after meals, acts 
most satisfactorily in hyperchlorrhydria to check the excess- 
ive secretion of hydrochloric acid. Its action is purely pal- 
liative, however, and constitutional treatment, especially in 
conjunction with out of door exercise and sponge baths, is 
necessary to eradicate this neurosis. Calc. carb. is to be 
thought of as a curative remedy. 

Anacardium is indicated in hyperacidity and gastralgia on 
the symptoms of pain and distress in the stomach relieved by 
eating. 

Kreosotum is useful where there is much fermentation and 
vomiting of thick, glairy mucus. 

Hydrastis is an excellent remedy in gastro-intestinal catarrh 
with constipation ; coated tongue ; loss of appetite ; gone 
feeling in stomach. 

Car bo veg., Lycop. and China are indicated especially by 
the presence of flatulence. Carbo veg. has belching of foul 
gas, with coated tongue and general venous stasis of the ab- 
dominal viscera ; Lycop. has flatus passed downwards, to- 
gether with dark urine which stains the diapers or causes the 
child to cry during micturition, from its irritating quality. 
In China there is usually colic, induced by the gas ; also 
eructations without relief ; also diarrhoea, anaemia, and ema- 
ciation. Other remedies which may prove useful are : 

Arg. nitr. — Flatulency and vomiting of quantities of ropy 
mucus, especially in the morning. 

Arscn. — After chilling the stomach with ice-water or ice- 
cream. Morning vomiting. Relief from hot food ; drinks 
little and often. 

Bry. — Loss of appetite, coated tongue ; thirst for large 
quantities of water at a time ; constipation. 



164 DISEASES OF CHILDREN. 

Calc. carb. — Scrofulous diathesis ; desire for eggs ; stools 
light and clay-colored. Acid dyspepsia in tuberculous sub- 
jects, the " pre-tuberculous stage " (Hughes). 

Ettonymin. — Bilious type ; tongue yellow, breath offensive ; 
slow pulse. — (Hale.) 

Hydrastis. — Large, flabby tongue ; catarrhal symptoms pre- 
dominate ; obstinate constipation. 

Ipecac. — After rich food and pastry ; tongue usually clean ; 
persistent vomiting. 

Phosphorus. — Regurgitation of food ; vomiting of water as 
soon as it becomes warm in stomach. 

Sulphur. — Skin dry and harsh, old appearance of child I 
aversion to being washed ; faintness and hunger in forenoon ; 
bright redness of the lips ; tongue furred in morning, wearing 
off during day ; child never seems satisfied, constant craving 
for food ; epigastrium sensitive to pressure, which causes 
eructations ; eczema. 

CYCLIC, OR PERIODIC VOMITING. 

In recent years attention has been called to the periodic 
occurrence of attacks of vomiting in children, not the result 
of indiscretions in diet with consequent acute indigestion, but 
rather due to a toxaemia of intestinal origin (auto-intoxica- 
tion). These children belong to the clinical type described 
as " lithaemic," but uric acid is not the cause of the attacks. 
While uric acid may be discovered in increased amounts in 
the urine prior to the attack and appear diminished or insuffi- 
ciently excreted during the attack, still this constituent of 
the urine must be looked upon rather as an index of the auto- 
intoxication than as the cause of the same. Rachford 
{Archives of Pediatrics, 1897) offers the most rational ex- 
planation of the cause of the attacks, namely, the formation 
in the system of alloxuric bodies of the xauthin group in suf- 
ficient amount to produce the symptoms noted. This group 
contains paraxanthin and heteroxanthin which are both toxic. 

Other etiological factors are heredity and a neurotic tern- 



DISEASES OF THE STOMACH. 165 

perament. Norton (Hahnemannian Monthly, March, 1903) 
found these factors well marked in his three reported cases. 
Rachford, Larned, Holt and others express similar views. 

Symptomatology. — Prodromes are not marked. There 
may be malaise, loss of appetite, a furred tongue and sourish 
breath, or the attack may be ushered in by vomiting. This 
is usually forcible, sometimes uncontrollable and the child may 
die of exhaustion (Marcy). In severe cases, as exhaustion 
sets in vomiting takes place without much effort and the 
vomitus consists of a thin fluid tinged with blood. 

At first the gastric contents are ejected and when the stom- 
ach has emptied itself retching sets in with the vomiting of a 
thin fluid containing bile and a little mucus and blood. Blood, 
however, is not necessarily present. Food and drink are not 
tolerated. Hydrochloric acid soon disappears from the gastric 
fluid and acetone and diacetic acid can be demonstrated in 
some cases (Edsall). These elements are also found in the 
urine pretty constantly. 

The bowels are constipated and the stools are lighter in 
color than normal, indicating a decrease in bile. Diarrhoea 
has been observed, but purging does not materially influence 
the vomiting. The abdomen is retracted, but there is no ab- 
dominal paim 

Fever is usually present. Ordinarily it is not high, but I 
have seen it reach 103 F. Anorexia is pronounced and there 
is intense thirst. The pulse is rapid and may become very 
weak, while the respiration is similarly affected. Convulsions 
have been observed. 

Pruritus and urticaria may be associated with the attack. 

The urine usually shows decided changes. It may be 
loaded with amorphous urates and uric acid, although at the 
height of the attack it generally becomes profuse and pale in 
color and of low specific gravity. A trace of albumen and 
granular casts are present in most instances. Acetone and 
diacetic acid are pretty constantly present (Morse; Bdsall). 
One is more likely to find these products just preceding or in 



166 DISEASES OF CHILDREN. 

the early stages of an attack (Pierson). Indican is present in 
increased amount, but disappears during the attack (Marcy). 

The duration is from two to four days. Convalescence is 
usually rapid, although in some of Snow's cases it was pro- 
tracted. There seems to be no distinct periodicity as to the 
recurrence of attacks. Einhorn, however, favors this view. 

The prognosis is favorable in the majority of cases, but 
when the child is frail and the intoxication is pronounced it 
becomes grave. Marcy has reported two fatal cases. 

Treatment — This must be chiefly prophylactic. The 
child's general condition is to be improved by fresh air, ex- 
ercise and careful regulation of the diet. Meat should be 
given sparingly to these children, but there is no doubt that 
an excess of starchy food, notably potatoes and oatmeal, tends 
to provoke attacks. Fruit, fats and milk may be given freely 
and the regular drinking of water is to be insisted upon. 
Nnx vomica and Lycopodium are usually indicated as there is 
more or less intestinal indigestion. 

During the attack it is best to stop the administration 
of any food, giving water freely. In incontrollable vomiting 
I make use of lavage. If the child be much prostrated this 
may be performed in the recumbent position. The bowels 
should be emptied by a glycerin enema (one ounce to six 
ounces of water), and this procedure followed by high colon 
injections of warm normal saline solution twice daily. By 
this means the distressing thirst is alleviated and the elimina- 
tion of toxins hastened. 

Pierson claims to have obtained beneficial results from the 
administration of Sodium bicarbonate. Its action is sup- 
posedly to neutralize the urine and aid in the diminution and 
neutralization of the uric acid, diacetic acid and acetone. 

The most satisfactory remedy in my experience for con- 
trolling the vomiting and nausea is Merc, dulcis, 2x trit., two 
grains every two to three hours. Norton recommends Cuprum 
ars. and Iris. 



DISEASES OF THE STOMACH. 167 

GASTRALGIA. 

The purely neuralgic type of gastric pain, or gastralgia, is 
seldom met with in the very young, and. if so, cannot be 
diagnosed for obvious reasons. The dyspepsias of infants are 
generally associated with pain, especially when there is much 
flatulence, and, naturally, gastritis is accompanied by gastric 
pain ; but in older children gastralgia without any objective 
disturbance can occur, as in the case of adults. 

Etiology. — A neuralgia of the stomach may result from 
exposure to cold and wet, drinking ice-water or eating very 
cold food, malarial infection, and other causes likely to induce 
neuralgic pains elsewhere. Irritation of terminal filaments 
of the pneumogastric will induce the identical condition, and 
so hyperacidity of the gastric juice is a frequent cause of 
these attacks. Certain articles of food may induce it with- 
out producing actual indigestion in some individuals, and the 
use of lemon-juice, vinegar and other acids often brings on 
severe pain. Predisposing causes are anaemia, neurasthenia, 
rickets and tuberculosis ; in some instances fright or anger 
seems to have precipitated an attack. 

Symptomatology. — The pains are paroxysmal, coming at 
intervals, between which the patient is entirely free from any 
discomfort. The paroxysm may have such prodromal symp- 
toms as yawning, pressure in the stomach and coldness of the 
extremities, or it may come on suddenly as a violent cramp, or 
as a pressing, burning or gnawing pain, so violent at times as 
to result in collapse. A characteristic feature of the pain 
seems to be its radiation from the spine and the tendency to 
reflect up into the region of the heart, often closely simulating 
angina pectoris. Sometimes the pain is temporarily relieved 
by eating. Firm pressure also may give relief. 

Diagnosis. — Gastralgia is to be distinguished from several 
important conditions, notably gastric ulcer* This is rare in 
children ; the pain is more constant ; it is aggravated by eat- 
ing; tenderness is also constantly present, and may be defin- 



168 DISEASES OF CHILDREN. 

itely located at one spot. The vomiting of blood usually 
occurs, verifying the diagnosis. 

In indigestion and gastritis there is the history of some 
error in diet or other cause for the trouble, together with 
vomiting and relief of symptoms thereby in the former, and 
continued fever, anorexia, vomiting of mucus and coated 
tongue in the latter. 

Other conditions in which pain is referred to as being 
located in the epigastric region are vertebral caries in the 
dorsal region and diaphragmatic pleurisy, which must be dif- 
ferentiated by their own peculiar symptoms. In pneumonia 
and pericarditis — no doubt through the involvement of the 
diaphragm — epigastric pain is also frequently complained of. 
Gall-stone colic may also occur in children. Here the exam- 
ination of the stools, the condition of the pulse, tenderness in 
the gall-bladder region and the subsequent symptoms will 
readily exclude simple gastralgia. 

Treatment. — During a paroxysm the patient must be put 
to bed, although, as a rule, rest is impossible from the agoniz- 
ing pain. Food should be withheld, and hot fomentations 
applied over the epigastrium. When this does not help, an 
ice-bag may be tried. Hot water internally, with a little 
brandy or gin added, often gives material relief. If the pain 
is uncontrollable a grain of Acetanilid with three grains of 
Sodium bicarbonate may be administered. 

After an attack the patient's habits must be regulated and 
a hygienic mode of living carried out. Irregularity in eating 
must be corrected, also the excessive use of starchy and sac- 
charine food. The diet should be highly nutritious and easily 
digested, especially in the neurotic class of patients. They 
should partake of milk, eggs, young meats, succulent vege- 
tables, bread and butter and stewed fruit liberally. Sufficient 
exercise and fresh air are of great importance. Cod-liver oil 
may be necessary in the scrofulous or rachitic. 

Arsen. — The pains are usually of a burning character, or 
purely neuralgic, resulting from the abuse of cold drinks or 
traceable to anaemia or neurasthenia. 



DISEASES OF THE STOMACH. 169 

Cuprum arsexicosum has proven clinically perhaps the 
best routine remedy in gastralgia. 

Bell. — Cramp-like pain extending into spine, relieved by 
bending backward (opposite to Co/ocynthis). Face flushed ; 
thirsty, but drinking aggravates. 

Bismitth. — Intense pressure on one spot ; relief from bend- 
ing backward. — (Bell.) 

Bryon. — Pressure in stomach as of a heavy load. Relief 
from rest. 

Calc. phos. — As a constitutional remedy between attacks. 
When anaemia is well marked, Ferrum phos. is preferable. 

Cha?n. — Tossing about in agony ; unmanageable ; after 
anger or vexation. 

Colocvxth. — Cutting pains concentrating in epigastrium, 
relieved by firm pressure and bending double (comp. Be//.). 

Ignatia. — Hungry gnawing in stomach ; faintness in epi- 
gastrium. Neurasthenia. 

Lycop. — Hungry feeling, but sudden repletion after eating 
a few mouthfuls. Lithaemia ; constipation ; flatulence. 

Nux VOM. — Clawing pain in stomach, extending into chest 
or downwards, producing retraction of anus ; ineffectual urg- 
ing to stool ; the pains are relieved by rubbing the stomach, 
belching and vomiting ; worse after eating, although there 
may be craving for food. Useful both during and between 
the attacks. 

PetroL — The pains are ameliorated by constantly eating 
something (Anac, Che/idonittm). 

malformations and malpositions. 

Atresia or stenosis of either the cardiac or pyloric end of 
the stomach in infancy is congenital ; later in life it may de- 
velop as the result of an inflammatory process either in the 
stomach or adjacent viscera, or, what is more likely to be the 
case, after the accidental swallowing of some caustic or cor- 
rosive poison, or from a burn. In the latter instances the 
stenosis, as a rule, involves the oesophagus and cardiac orifice 
of the stomach. 

12 



170 DISEASES OF CHILDREN. 

The congenital form terminates fatally within a few days, 
while the acquired form may be relieved by surgical inter- 
ference. Persistent vomiting is the only positive symptom. 
Locating the obstruction with the oesophageal bougie con- 
firms the diagnosis. 

Spasmodic stenosis of the pylorus may occur with every 
symptom of congenital stenosis, with this exception, that the 
obstruction is not permanent and the case recovers. It may, 
however, result in permanent stenoses by setting up an hyper- 
trophy of the tissues about the pylorus. The condition is 
described below (see " Dilatation of the Stomach "). 

As regards position, the stomach may assume a vertical 
direction, or be located in the thoracic cavity in cases of 
diaphragmatic hernia. I am not cognizant of enteroptosis 
having been observed in early childhood, although it is not 
uncommon in young adults, particularly neurasthenic females 
of spare habit. Any wasting illness by inducing absorption 
of the fat of the abdominal wall and relaxation of the sup- 
ports to the viscera predisposes to the displacement of the 
stomach. 

CONTRACTION OF THE STOMACH. 

The stomach may be abnormally small from a congenital 
defect, or it may contract as a result of continued vomiting, 
insufficient feeding, or lack of use and the general atrophy 
accompanying marasmus. The condition can only be di- 
agnosed by an actual measurement of the gastric contents, 
while the treatment must be directed towards creating tol- 
erance for a gradually increasing quantity of food, given at 
regular intervals. 

DILATATION OF THE STOMACH ; HYPERTROPHIC PYLORIC 
OBSTRUCTION. 

Dilatation of the stomach is of more frequent occurrence 
in children than in adults, although the causes producing this 
condition most commonly in adults are quite rare in children. 



DISEASES OF THE STOMACH. 171 

On the other hand, etiological factors of no moment to the 
adult may produce a marked degree of dilatation in an infant. 

Etiology. — Dilatation may take place rapidly during the 
course of an acute gastritis or cholera infantum. It is usually, 
however, secondary to chronic indigestion or chronic gastritis, 
as a result of the long-continued distention of the stomach by 
the slowly digesting food and the gases which generate in 
these conditions. The obstruction of the pyloric end of the 
stomach with tenacious mucus is to my mind an important 
etiologic factor. 

The general muscular atony of rickets is a prominently 
predisposing cause, and in chronic gastritis there is a similar 
relaxed condition of the muscular wall of the stomach. In 
the latter condition there is at the same time a certain amount 
of pyloric obstruction, resulting from the thickened state of 
the mucous membrane and the tenacious mucous secretion. 
Pyloric obstruction may result also from inflammatory ad- 
hesions ; pressure from an abdominal tumor ; congenital 
defect and even malignant disease, although this is quite rare. 

Dilatation not dependent upon pyloric obstruction is usually 
the result of giving the food in too large quantities, especially 
when this becomes necessary in order to satisfy the child's 
hunger on account of the food being insufficiently nutritious. 
Feeding the babe with condensed milk is therefore a frequent 
cause. I have also seen dilatation result in several instances 
from the use of proprietary foods containing malt in some 
form, which through fermentation set up sufficient distention 
to dilate the stomach. In such cases we can withdraw a 
large quantity of a brownish, offensive fluid from the stom- 
ach by inserting the lavage apparatus. 

Hypertrophic pyloric obstruction is a condition that has re- 
ceived special consideration of late and numerous cases have 
been reported, although a large number of such have un- 
doubtedly been spasmodic in type. It is therefore necessary 
to differentiate between true hypertrophic stenosis and pyloric 
spasm. Thompson was of the opinion that all of these cases 



172 DISEASES OF CHILDREN. 

were primarily spasmodic in origin, the excessive contraction 
of the pylorus eventually leading to hypertrophy of the mus- 
cular coats. This theory, however, does not explain the de- 
velopment of the actual hyperplasia of the epithelial and sub- 
mucous coats associated with the hypertrophied and infiltrated 
muscular coats in some of the reported cases, nor does it 
throw any light on the nature of the spasm. From personal 
observation I am led to believe that the purely spasmodic cases 
owe their origin to an excessive acidity of the gastric juice 
or to the development of irritating foreign products in the 
gastric contents in sufficient amount to cause ovei-stimulation 
and contraction of the pylorus. These are, notably, lactic, 
acetic and butyric acid. iVgain, the clogging of the pyloric 
end of the stomach with tenacious mucus is another factor 
that must be taken into consideration. The fact that I have 
been able to control a number of such cases with systemati- 
cally applied lavage strengthens my views on this point. I 
have also made mention on a previous occasion {North Amer. 
Jour, Horn., Dec, 1903) of the fact that in some of my cases 
of gastric dilatation there was hyperacidity of the gastric 
contents. 

Congenital gastric spasm is therefore a condition of irrita- 
bility of the circular muscular fibres at the pyloric end of 
the stomach, existing from the time of birth, in which case 
it is fair to suppose the pylorus to be congenitally hyper- 
trophied and irritable, or becoming so later as a result of direct 
irritation. It may be of short duration or persist until hyper- 
trophy sets in, and if the irritation be sufficient to induce 
inflammatory changes, hyperplasia of these structures ensues. 
Most of the cases so far reported have been fatal. This is, 
no doubt, explained by the fact that many of the more benign 
type of cases escape recognition. I have recently had under 
observation a well marked case with persistent vomiting ; 
emaciation ; dilatation of the stomach and peristaltic waves 
plainly visible in the gastric area, which ultimately made a 
complete recovery. 



DISEASES OF THE STOMACH. 173 

Symptomatology. — The stomach is usually symmetrically 
dilated, with a preponderance of the deformity at the cardiac 
end. At times the greater curvature may reach below the 
umbilicus, in which case the normal contour of the organ is 
much changed, giving it the appearance more of a bagpipe 
than of a stomach. These extreme cases are, however, rarely 
encountered. 

The physical signs are epigastric bulging and a tympanitic 
percussion-note, together with splashing when there is fluid 
in the stomach. Chronic indigestion, belching, vomiting of 
large quantities of partly-digested food, and often inter- 
ference with the function of adjacent organs, are the accom- 
panying symptoms. 

In congenital gastric spasm the stomach is dilated and per- 
istaltic waves can be seen passing across the epigastrium 
toward the pylorus. In the hypertrophic variety the thick- 
ened pylorus can at times be palpated in the epigastric region 
just to the right of the median line. Vomiting is the cardinal 
symptom, but it is not always continuous, as the obstruction 
tends to give way at irregular intervals. At such times milk 
residue will appear in the stool, while ordinarily the stools 
are scanty and infrequent, consisting mainly of mucus and 
bile. 

Diagnosis. — To positively diagnose the condition, an exact 
outline of the organ and a determination of its capacity must 
be obtained. Often we are enabled to percuss satisfactorily 
the abdomen three, to four hours after eating. If this yields 
unsatisfactory results, half a Seidlitz powder may be administ- 
ered, or the stomach filled with water. The latter procedure is, 
however, not entirely without danger in all cases, and is 
not to be employed haphazard. The lower border should not 
extend beyond half the distance between the umbilicus and 
ensiform cartilage; anything below this indicates dilatation. 

Extension of the tympanitic note to the left is also impor- 
tant, indicating dilatation of the cardiac end. The phonendo- 
scope is often of service to determine the outline of the 



174 DISEASES OF CHILDREN. 

organ by placing its stem in the region of the fundus and 
observing the changes in sound occurring by stroking the 
finger in different directions (ausculatory percussion). 

Splashing can be obtained where there is gas and fluid 
present. 

Dilatation of the colon is to be differentiated by the con- 
cave outline of the lower border of the distended area ; it 
is convex in dilatation of the stomach. Besides, the result 
obtained from the administration of a Seidlitz powder, to- 
gether with the clinical features of the case, must be taken 
into consideration. The best results are obtained when the 
powders are dissolved separately and thus taken, allowing the 
generation of the gas to take place entirely within the stomach. 
Naturally for a child a fraction of the powder suffices. 

Pyloric obstruction is diagnosed by the persistent vomiting 
and the absence of true fecal matter in the intestines. Per- 
istaltic gastric waves are pathognomonic of the condition. 
It is impossible to say whether a case is purely spasmodic or 
hypertrophic in character unless a sudden cessation of symp- 
toms takes place, or the hypertrophied pylorus can be palpated. 

Treatment. — The prominent indication for treatment is 
the indigestion which is present in these cases, being best 
overcome by a careful regulation of the diet according to 
the rules laid down in the chapter on "Feeding." Whey and 
broths are more applicable than milk. Lavage is also of 
prime importance, especially when there is gastric catarrh 
or ^ vomiting. The auxiliary measures and remedies men- 
tioned under "Chronic Indigestion" are to be consulted. 
Naturally, any food capable of undergoing fermentation must 
be avoided, and even in preparing a milk formula it will be 
well to decrease the percentage of sugar if gas develops in 
the stomach. 

In pyloric obstruction a surgical operation is the last resort 
when systematic stomach washing and careful feeding fail to 
give relief. It is best to restrict the diet to whey, broths, 
meat juice and albumen water. Milk is not tolerated as the 



DISEASES OF THE STOMACH. 175 

casein cannot pass through the narrowed pylorus. Malted 
foods are also contraindicated as they tend to ferment in the 
stomach. 

ULCER OF THE STOMACH. 

The round perforating ulcer of the stomach is very rare, 
but it has been met with at all periods of infancy and child- 
hood. Its anatomical characteristics are identical with the 
gastric ulcer of adults, although this variety of ulcer is more 
frequently found in the duodenum than in the stomach. 
Cade reports a typical case in an infant two months old, death 
resulting from perforation. He was able to collect twenty cases 
from the literature, the ages varying from several hours to thir- 
teen years. Henoch (Beitrage zur Kinderheilkunde, 1861) 
repeatedly met with the condition clinically. Adrian ce {Ar- 
chives of Pediatrics) reports a peptic ulcer in the duodenum 
of an infant ten months old. 

A second variety is the tuberculous ulcer, which is also rare. 
A third variety is follicular ulceration, which is most fre- 
quently found in the newborn. Rotch cites a typical case 
occurring in a girl one year old (Pediatrics). 

I have on several occasions encountered follicular ulcera- 
tion in the stomach and bowels of the newborn dying either 
of indefinite symptoms or with those of melena (see Diseases of 
the Newborn). The mucous membrane of the stomach is 
found studded with numerous ulcers of circular outline and 
about the size of a split pea. They may coalesce and form 
irregular patches. In some the superficial epithelium alone 
is destroyed, while others extend into the sub-mucosa, 
causing considerable haemorrhage. The stomach contains 
a tenacious mucus which is stained blackish from the 
admixture of blood. The greatest number of lesions was 
found at the cardiac end and at the fundus of the stomach. 
The colon was at the same time involved in a similar follicu- 
lar inflammation with ulceration. The small intestine seems 
to escape, no doubt owing to its alkaline reaction. In this 



176 



DISEASES OF CHILDREN. 



respect, aphthous stomatitis seems to bear a close relationship 
to trie above process, only developing in the mouth when the 
normal alkaline secretion has become diminished or vitiated. 

Symptomatology. — Localized tenderness, gastric pain es- 
pecially aggravated by eating, and the vomiting of blood, or 
bloody stools, are the cardinal symptoms. These are, how- 
ever, not always present, and often a positive diagnosis can- 
not be made. Perforation may occur, resulting in collapse 
and peritonitis. Colgan cites a case of round perforating 
ulcer, the presence of which was not suspected until perfora- 
tion took place. 

Treatment. — If gastric ulcer be suspected, the child should 
be put to bed and kept on a milk diet. In case of haemor- 
rhage food should be withheld, ice may be given, and rectal 
alimentation instituted. The most important remedies from 
the clinical standpoint are Arsenicum, Argentum nitricum, 
Mercurius corrosivus and Phosphorus. 

CANCER OF THE STOMACH. 

Malignant disease of the stomach is exceedingly rare during 
childhood, but it has been met with occasionally. Culling- 
worth has reported a case of columnar epithelioma occurring 
in an infant five weeks old. Ashby and Wright {Diseases of 
Children) report the case of a boy aged eight years who died 
of a columnar epithelioma involving the stomach and duo- 
denum. In this case a tumor could be felt below the edge of 
the liver, to the right of and on a level with the umbilicus. 
There was abdominal tenderness and distention, frequent at- 
tacks of colicky pains and gradual emaciation. 



CHAPTER VIII. 

DISEASES OF THE LIVER. 

The position and relative size of the liver varies with the 
age of the child ; thus, in the new-born its weight is approx- 
imately 4 per cent, of the body-weight, at six months 3 per 
cent., and in adults 2.5 per cent. Its lower border reaches 
nearly to the crest of the ilium in infants when in the up- 
right position (McClellan), while the upper border reaches 
the fifth intercostal space in the mammary line, the seventh 
in the axillary, and the ninth posteriorly. The low position 
occupied by the inferior border of the liver, in comparison 
with adults, is not entirely due to the greater development of 
the organ, but must be explained also by the structural pecu- 
liarities of the thorax, for the ribs, by their more horizontal 
direction, cover the liver to a less extent than the elongated 
thorax of the adult (Sahli, u Topographische Percussion im 
Kindesalter"). During the entire period of childhood the 
liver edge can be felt extending somewhat below the costal 
margin. 

The examination of the liver comprises palpation and per- 
cussion. Often the lower edge can be distinctly seen, in 
emaciated subjects. 

In order to palpate the liver the child is placed in the 
prone position and if the abdominal walls be rigid the thighs 
may be slightly flexed by an assistant. With the tips of the 
first three fingers of the right hand gently pressed into the 
abdomen, the examiner feels for the edge of the organ by 
working from below upward (Fig. 14). Note whether the 
edge be sharp and regular in contour or whether it be rounded 
and irregular. Also judge of its consistency, i. e., whether it 
be softer or firmer than normal. 

In the prone position the deep dulness reaches up to the 



178 DISEASES OF CHILDREN. 

fourth interspace in trie mammary line and seventh interspace 
in the mid-axillary. The superficial dullness begins at the 
upper border of the sixth rib in the mammary line and blends 
with the cardiac dullness in the parasternal line. In the 
axillary line it crosses the eighth rib and posteriorly the tenth 
rib. The percussion stroke should be light in eliciting these 
boundaries but for the deep dulness it must be moderately 
strong. 

JAUNDICE ; ICTERUS. 

With the exception of the jaundice peculiar to the new- 
born, the symptom indicates nothing different from the con- 
ditions capable of producing it in adults. Icterus neonatorum 
is a physiological condition and has been described in a pre- 
ceding chapter. 

Jaundice is the result of an obstruction in the gall-ducts or 
in the common duct. This may happen from a variety of 
causes. 

It may be due to congenital stricture or the accidental en- 
trance of a round worm into the ductus communis choledochus. 
The pressure of a new growth or the lodgment of gall-stones 
in the duct are rare occurrences in children. The commonest 
form of jaundice is catarrhal. 

Catarrhal jaundice depends upon a catarrh of the duode- 
num and gall-ducts, the swelling of the mucous membrane, 
together with the production of tenacious mucus, inducing 
the obstruction. It is most frequently seen after the third 
year of life. The accompanying symptoms are headache and 
lassitude, anorexia, diarrhoea, or, more commonly, constipa- 
tion, the stools being light in color and very fetid ; high-col- 
ored urine, due to the presence of bile-pigments, and occa- 
sionally slight fever at the commencement of the attack. 
The liver is slightly enlarged (Fig 14). A marked reduction 
in the pulse-rate, which is the case in adults, does not take 
place at this age. 

This affection is not uncommon in children ; some show 






DISEASES OF THE LIVER. 179 

the disposition to jaundice from infancy. Indigestion and 
constipation, often obstinate, are as a rule associated and 
sometimes round worms are abundantly present, marked 
improvement following upon the exhibition of santonin. A 
distinct gouty family history may exist. 

CHOLELITHIASIS. 

Although cholelithiasis is rare during childhood, still we 
are likely to encounter it at times, and must not lose sight of 
this fact in the differential diagnosis of painful abdominal 
affections. 

I recall the case of a child four years old which presented 
the history of an attack of gall-stone colic three months prior 
to the time I saw it ; and in a three-year-old boy suffering 
with violent abdominal pains I was able to demonstrate 
minute biliary calculi passed with clay-colored stools several 
days after the attack. Since then I have noted two other 
such cases. Many cases are undoubtedly overlooked, being 
looked upon as gastralgia or intestinal colic. A condition 
from which cholelithiasis must be differentiated is appendicu- 
lar colic, which, according to Van Lennep, is common in chil- 
dren, owing to the patency of the opening to the appendix. 

ACUTE YELLOW ATROPHY. 

This is one of the rarest diseases of childhood, only about 
fifteen cases being on record, according to L,anz (" Wiener 
Klinische Wochenschr." 1896). Fison (Lancet, July, 1897) 
reports a case in a girl twelve years old, giving detailed 
autopsy findings. It must be considered in the differential 
diagnosis, of obscure serious ailment by which the nervous 
system is profoundly affected. Simulating a simple catarrhal 
jaundice in the beginning, the symptoms gradually assume a 
most alarming type, delirium, uncontrollable vomiting, dila- 
tation of the pupils, coma and convulsions developing. The 
urine contains bile pigments, leucin and tyrosin ; in Lanz's 
case albumin and acetone were also present. The tempera- 



180 DISEASES OF CHILDREN. 

ture rises with the progress of the disease and the spleen en- 
larges. Other symptoms which may be observed are pro- 
gressively-increasing jaundice, slight oedema of the extremi- 
ties, atrophy of the liver, ecchymoses and bleeding from the 
gums. A fatal termination usually takes place within a few 
weeks from the onset, or, exceptionally, within a few days. 
The liver appears wrinkled and of a yellow-ochre tint, the 
lobules becoming indistinct. The hepatic cells are filled 
with granules and the tissue is largely replaced by granular 
and fatty debris contained in a reticulated homogenous 
structure. 

CIRRHOSIS OF THE EIVER. 

Cirrhosis of the liver is much rarer during childhood than 
during adult life, as alcoholic excess, the chief etiological factor 
producing this affection, is only in exceptional cases operative 
at this age, the other cases being regarded as syphilitic and 
tuberculous, although the eruptive fevers are considered by 
L,aure and Honorat (Hoi/r) capable of producing interstitial 
changes in the hepatic glandular structure. Morse {Boston 
Med. and Surg. Jour., Sept. 1 1, 1902) states thatin hospitals the 
disease has been encountered one in twenty thousand cases. He 
looks upon intestinal auto-intoxication as a probable cause. In 
early infancy it is seen in association with obliteration of the 
bile ducts (congenital) as biliary cirrhosis. Syphilitic cases 
and those peculiar to India are also seen in early infancy. 

The toxins of tuberculosis may cause cirrhosis with tuber- 
cles being present. Organic heart disease may also be followed 
by interstitial changes in the liver. 

The hypertrophic variety is most frequently met. with, es- 
pecially when traceable to syphilis. Only when the inter- 
stitial changes are pronounced will symptoms referable to the 
liver be induced, in which case the course is the same as in 
adults. More commonly, however, the cirrhosis is not sus- 
pected, being either masked by the symptoms of the exciting 
cause (congenital syphilis, tuberculous peritonitis, etc.), or 



DISEASES OF THE LIVER. 181 

there are insufficient symptoms to give a distinct type to the 
disease. 

Treatment of Hepatic Diseases. — In selecting the diet for 
hepatic disturbances, we must consider the digestive as well 
as the assimilative functions of the liver. The role of the 
biliary secretion in the digestion of fats renders it necessary 
to cut down the percentage of fat in the food, as intestinal in- 
digestion or a fat diarrhoea will result from an excess of this 
food when the bile is deficient in amount. Carbohydrates, 
being stored up in the liver, must also be given sparingly. A 
milk formula, with a reduction in the percentages of fat and 
lactose, will be indicated in infants ; older children may be 
put on the ordinary milk diet, together with fresh, succulent 
vegetables, light meats, and stewed fruit. Water must be ad- 
ministered abundantly. 

Acute yellow atrophy is universally recognized as being in- 
variably fatal, and symptomatic treatment is all that can be 
instituted to ameliorate conditions as they arise. Cirrhosis 
has been benefitted by anti-syphilitic treatment, and the alco- 
holic form can be arrested if taken in time. 

Remedies which will be indicated by the presence of 
jaundice, and evidence of g astro-duodenitis or acute intestinal 
catarrh, are Berberis, Bry., Calc. card., Cham., Chelid.^ China, 
Digit., Gels., Leptandra, Merc, Myrica cerif., Nux vomica, 
Podoph., Pulsatilla, Sulph. Of these, Bryonia, China, 
Mercurius vivus and Nux vom. are the most useful and most 
frequently indicated, mainly from their characteristic symp- 
toms referable to the tongue, thirst, appetite, stool, etc. 

The tendency to the formation of gall-stones is markedly 
influenced by China. For the painful symptoms, Bell., Bry., 
Cham., Nux vom. and Calc. carb. are occasionally of use, 
although hot fomentations, and in extreme cases an anodyne 
or anaesthetic, will become necessary. A mild saline aperient, 
the best of which is the Carlsbad Sprudel Salt, is of great 
value to prevent the accumulation of mucus in the bile ducts 
and avoid the baneful effects of constipation. 






182 DISEASES OF CHILDREN. 



Hepatitis or organic changes in the liver may require Aco?i. %i 
Arsen., Bell., Bry., China, Hepar, Mercur., Lack., Nux vom. 
for the acute symptoms, and Calc. carb., Conium, Iod., Kali 
carb. or Phosphorus for the chronic pathological condition 
which may be present. Phosphorus is homoeopathic to fatty 
changes, and is frequently useful in fatty degeneration and 
in cirrhosis ; for the last mentioned condition, Aurum muri- 
aticum is also a valuable remedy. The old school has of 
recent years claimed good results from the use of minute 
doses of Calomel in cirrhosis of the liver. 



CHAPTER IX. 

DISEASES OF THE INTESTINES. 

During infancy the process of digestion takes place most 
prominently in the small intestines, as the stomach is not 
fully developed at this period of life, and must be considered 
more as a reservoir for food than the principal organ of diges- 
tion, although pepsin, rennin and free hydrochloric acid have 
been found in small quantities in the stomach of the new- 
born. The important change taking place in the milk while 
in the stomach is its coagulation by rennin. The action of 
rennin, which is an enzyme, is to coagulate, or clot the case- 
inogen (the original proteid) into casein. The next step is the 
action of the hydrochloric acid of the gastric juice upon the 
coagulated rrtilk, the product being paracasein chlorid. A 
portion of this is subsequently attached by the pepsin. The 
curdling of milk through souring is purely a precipitation of 
the proteid and the addition of an alkali will cause it to be re- 
dissolved. This does not take place when rennin has coagu- 
lated the casein. The bulk of the work of digestion is there- 
fore thrown upon the intestinal tract, gastric digestion being, 
so to speak, a preparatory step. For this reason disturbances 
are more frequently found here than in the stomach. 

The intestinal tract is relatively larger in children than in 
adults, being six times the body-length in the new-born, while 
in the adult it is but four times (Beneke). The sigmoid 
flexure is notably long, constituting one-half the length of the 
greater bowel. 

Intestinal digestion is very active in the normal infant owing 
to the large amount of bile secreted, which saponifies the fats 
and stimulates peristalsis. Trypsin and steapsin are also ac- 
tively secreted, the former peptonizing proteids and the latter 
emulsifying fats. After the third month the diastatic ferment 



184 DISEASES OF CHILDREN. 

of the pancreatic juice (amylopsin), which has the power of 
converting starch into sugar, makes its appearance, so that 
it becomes possible for the infant to digest farinaceous foods. 
This form of digestion is, however, not fully established until 
the time of the eruption of the teeth, before which time it is 
unwise to use starchy food unless predigested. The muscular 
coats of the intestines are poorly developed at this period 
of life. 

A rational understanding of the diseases of the intestinal 
tract presupposes an intimate knowledge of the character and 
composition of the stools in health and in disease. Without 
this knowledge it is impossible to diagnosticate the various 
disturbances of the functions of the intestine or pathological 
lesions here found. Besides, we will often fail to understand 
the true nature of an apparently obscure constitutional dis- 
order if we neglect to investigate the intestinal discharges for 
evidence of intestinal parasites, which frequently affect the 
general health to a marked degree. 

Unfortunately, the examination of the faeces impresses the 
average physician as a repulsive procedure, and the benefits to 
be derived from such an examination are held inadequate 
compensation for the unpleasantness of the task involved. 
But with proper technique this is not the case, and especially 
so in infants. In paediatric work there is positively no 
excuse for neglecting such an examination whenever it is 
called for. 

In older children a specimen of fecal matter is best obtained 
by inserting a piece of glass tubing with rounded ends into 
the rectum, for a distance of about three inches, and allowing 
it to remain in place five minutes. By the end of that time 
the peristaltic action of the rectum will usually have filled 
the tube. In infants a freshly soiled diaper can, as a rule, be 
obtained without difficulty, although, when we wish to be ab- 
solutely certain that no urine is admixed with the stool, we 
will have to resort to the tube. 

The Normal Infantile Stool. — Shortly after birth the infant 



DISEASES OF THE INTESTINES. 185 

passes three to four stools, consisting of meconium, — a thick, 
tarry substance, representing the biliary and mucous secre- 
tions that have collected in the intestinal tract during intra- 
uterine life, besides epithelium and particles of vernix caseosa 
and hairs. Folio wiug this the normal milk stools make their 
appearance. 

The normal milk stool is of a golden-yellow color and of a 
thick, smooth, pasty consistency, without definite formation. 
The odor is slightly sour, not offensive, and the reaction is 
acid. A large percentage of water is present, so that a ring 
of moisture surrounding the fecal matter forms on the diaper. 
This ring normally extends for a finger's breadth around the 
stool ; any considerable increase in moisture beyond this point 
is abnormal. In the early months of infancy there are from 
three to four stools in twenty-four hours ; by the end of the 
first year the number is decreased to one or two. 

The first abnormal condition to be observed in intestinal 
disorders is an increase hi the size and in the frequency of the 
bowel movements. This means intestinal indigestion, or dys- 
peptic diarrhoea. When we pause to reflect that the main 
work of digestion, and practically all of assimilation, takes 
place in the small intestines of the infant, we must be im- 
pressed by the fact that such a condition may be the forerun- 
ner of most serious consequences. 

In the dyspeptic stool we discover, first of all, particles of 
undigested milk, "Milchdetritus," almost universally and erro- 
neously designated " curds." Far from representing mere 
particles of undigested casein, their composition is most com- 
plex and variable. While casein in greater or less proportion 
may be present in these clumps of fecal matter, still their 
composition is chiefly of fat, together with fatty acids and 
lime-salts. Indeed, in some forms of diarrhoea the fat per- 
centage is so high (30 per cent, to 50 per cent.) that the con- 
dition has been designated " fat diarrhoea " (Biedert ; Demme). 

Together with the above alterations in the character of the 
stool, there is also a change in the color, manifesting itself as 

J 3 



186 DISEASES OF CHILDREN. 

an admixture of green. The green color is due to the pres- 
ence of biliverdin. Several explanations for its presence may 
be offered. In the first place, bacterial changes in the intestinal 
tract, by which the bilirubin is oxidized into biliverdin, may 
change the color of the stool to green already in the intestinal 
tract. In other cases there is simply an excess of bile, which 
is promptly oxidized on exposure to the air, the stool thus be- 
coming more and more green as it stands. 

Again, as Pfeiffer {Jahrbuch fur Kinderheilk., 1888) points 
out, the green color in the stool depends upon the action of 
an alkali on the bilirubin and does not signify acid fermenta- 
tion, as was formerly taught. The important point to re- 
member is that while an alkali changes the color to green, an 
acid does not convert it back again to yellow. Therefore, an 
alkaline zone must exist somewhere in the intestinal tract — 
the alkali being most likely derived from the pancreatic juice. 
The reason for its excessive action is either feeding milk in 
too large quantities, thus neutralizing the gastric contents 
completely, or hypo-acidity of the gastric juice. After the 
intestinal contents have passed this alkaline zone, they may 
again become acid through the action of the bacillus lactis 
serogenes. 

Another cause of green stools is the chromogenic bacillus 
described by Le Sage. This is rarely present. 

The admixture of green and yellow, together with the white 
particles of "Milchdetritus," produces the characteristic ap- 
pearance described as chopped eggs and spinach. 

A further abnormal change in the stool is an increase in its 
fluid elements. Blood serum is always freely poured out in 
inflammatory conditions of the intestinal mucosa, and in 
cholera infantum the evacuations consist essentially of serum. 

Increase in the Number of Stools. — An increase in the num- 
ber of stools indicates either that the food is being hurried 
through the intestinal tract in an undigested state or that an 
inflammatory condition has supervened. Increased peristalsis 
is an important factor in both conditions. In dyspepsia there 






DISEASES OF THE INTESTINES. 1ST 

may be from four to six stools daily. In inflammatory condi- 
tions of the upper bowel the stools are large, increased from 
six to eight daily and, as a rule, expelled with considerable 
flatus. Gastric symptoms are a frequent accompaniment. On 
account of the fermentation taking place in the bowels the 
abdomen is distended. When the lower bowel is affected the 
stools are smaller in size and more frequent, while involve, 
ment of the rectum produces tenesmus that may practically 
be continuous. In such cases only a small amount of faecal 
matter is passed, but considerable mucus and usually some 
blood are present. 

Decrease in the Number of Stools. — An abnormal decrease 
in the number of stools is designated constipation, when due 
to deficient peristalsis, insufficient or improper food, or abnor- 
mal dryness of the mucosa. The various forms of bowel ob- 
struction cannot be considered here. 

Mucus. — Mucus is found in insignificant amount in both 
normal and dyspeptic stools, but in inflammatory states it is 
always present in considerable quantity. In fact, in catarrh 
of the intestine, it may be the chief, if not the sole, constitu- 
ent of the movements. 

The character of the mucus offers most valuable data in the 
recognition of the seat of the lesion in inflammation of the 
bowel. When thoroughly admixed with the other elements 
of the stool and stained with bile, it comes from the small 
intestine. Under these circumstances gas usually accumu- 
lates in the intestines and the abdomen becomes distended. 

Mucus coming from the large intestine is more abundant, 
not so intimately admixed with the fecal matter, and not 
thoroughly bile-stained. The mucus secreted from an in- 
flamed rectum is passed in clear, jelly-like lumps, blood- 
streaked. 

Blood. — Profuse haemorrhage from the intestine most com- 
monly originates in either tuberculous or typhoid ulcers. 
Haemorrhoids are rare in children, but rectal polypi are not 
uncommon. 



188 DISEASES OF CHILDREN. 

Blood from the small intestine gives the stool a dark, tarry 
appearance. In the newborn, intestinal haemorrhages are at 
times encountered, the blood coming from folliculous ulcers 
in the stomach or large intestine (melena neonatorum). 
Blood passed in fresh clots comes from the rectum or lower 
part of the colon. Small quantities thoroughly admixed with 
the stool in diarrhoea originate in capillary haemorrhages. 

Color. — The color of the stool is affected in a pronounced 
manner by certain drugs and by the food. As above stated, 
the normal milk stool is of a golden yellow. Excessive 
amounts of fat may give it a grayish color, while excess of 
proteids usually brings about greenish discoloration. Barley- 
water and meat-juice tend to give it a brownish color. In 
obstructive jaundice the stool becomes clay-colored. Calomel 
produces a decidedly green stool, loose in character. Bismuth 
and Iron cause the stool to turn black. 

Chemical Examination. — The chemical examination of the 
faeces has yielded data of the highest clinical importance. In 
this connection the odor may be considered, as it depends 
upon chemic changes in the food induced mainly through 
the agency of bacteria. 

The sour odor of the infantile stool depends upon the pres- 
ence of fatty acids and to the action of the bacillus lactis aero- 
genes upon the lactose, which is transformed into lactic and 
butyric acids. Under pathological conditions, acetic, formic 
and other organic acids may appear. 

A foul odor indicates decomposition of proteids into tyrosin, 
indol, skatol and phenol. This is encountered in the severer 
forms of infectious diarrhoea. 

The reaction is acid in the majority of diarrhoeas. Baginsky 
states that it is likely to be alkaline when the odor is foul, in- 
dicating the presence of ammonia compounds from decomposi- 
tion of proteids. From extended personal observations I 
have come to the following conclusions : • 

In dyspeptic diarrhoea, or in affections of the upper intes- 
tinal tract, the reaction is acid. This, no doubt, depends 



DISEASES OF THE INTESTINES. 189 

upon the fact that in the small intestine the bacillus lactis 
aerogenes predominates. Besides, in these affections, mucus 
and serum are not as abundant as in affections of the lower 
tract. 

Stools from the lower tract are, as a rule, alkaline. Here 
the bacillus coli predominates and proteid decomposition is 
most active. Moreover — more mucus and serum enter into 
the composition of the stools from this region. I have in- 
variably found that where mucus was abundant the reaction 
was either alkaline or neutral. Blood serum being alkaline 
naturally tends to render the stool so. 

Neutral stools are frequently seen. A combination of causes 
seems to be active here. 

Bile pigments are increased in catarrhal conditions, biliver- 
din predominating. Stercobilin (identical with urobilin), 
the coloring-matter of the stools, is not found in any consider- 
able amount owing to the absence of putrefactive changes, 
but hydrobilirubin — a reduction compound of bilirubin — is 
found when fermentation with the liberation of hydrogen oc- 
curs. It can be readily detected by the corrosive sublimate 
test. 

Blauberg (Experimentelle u. kritische Studien Ueber 
Sang ling sfceces, Berlin, 1897) has made the following ob- 
servations in his careful work in this line : 

The green color of the stools is due to biliverdin, which not 
only develops after exposing the faeces to the air, but which is 
always present in the slightest digestive derangement. He is 
inclined to think that certain ferments play an important role 
in its production. The sour odor depends upon free fatty 
acids and butyric acid. 

The amount of nitrogenous compounds averages about 4 
per cent. 

Fat is found in considerable quantity in the faeces during 
the early weeks of infancy, but under normal conditions a de- 
cided decrease in this ingredient occurs after the seventh and 
eighth days. An actual fat diarrhoea may occur in the new- 



190 DISEASES OF CHILDREN. 

born, indicating that it must accommodate itself to breast 
milk as well as to any other food. Chapin {Archives of 
Pediatrics, July, 1903) expresses similar views, basing his 
argument upon a study of the evolution of mammals. He 
writes as follows : " While the stomach, of an infant is 
formed at birth, its function is not developed. Strictly speak- 
ing, then, an infant has no stomach at birth, as it does not 
secrete pepsin and hydrochloric acid, but a dilated sac that 
develops into a true stomach during the suckling period." 

Lactic acid, fatty acids and iron are present in larger 
amounts in the faeces of breast-fed than in bottle-fed infants. 

When cow's milk is fed there is a larger proportion of fat, 
nuclein, lime-salts and phosphoric acid. 

The gases represent the products of lactose fermentation, 
together with some swallowed air and C0 2 . Normally, they 
are never foetid. 

Diastatic and invert ferments are normally present. 

Microscopical Examination. — If a bit of normal faeces be 
placed upon a slide with a drop of normal saline solution and 
examined with a low power, we will not find much of inter- 
est. Small particles of nitrogenous matter, fat globules and 
crystal of fatty acids, traces of mucus, a few epithelial cells 
and debris constitute the chief elements. Animal parasites 
are absent. The normal bacteria will be considered further 
on. 

When the child is artificially fed, the findings in the micro- 
scopical field will depend upon the nature of the food admin- 
istered. Under these conditions it is also not infrequent for 
animal parasites to show themselves. 

The various cereals used in infant feeding leave a con- 
siderable amount of indigestible vegetable debris in the stools, 
representing the cellulose walls of the cells in which the 
starch-grannies are contained. From an examination of a 
large number of diarrhceal stools in which barley-water and 
other cereals were used as a diet, I have been led to 
believe that these foods are not without their drawbacks in 



DISEASES OF THE INTESTINES. 191 

inflammatory states of the intestinal mucosa. In this belief 
I am still further strengthened by the following findings, 
which indicate the microscopic appearance of the different 
cereals under different conditions : 

Bar ley-Water Made from the Grain. — (In these examina- 
tions a two-third-inch objective and a one-inch eye-piece were 
used.) The field contains broken-down starch-granules and 
homogeneous starchy material, together with a large amount 
of cellulose detritus, wooden in appearance. The bits of 
cellulose structure represent clusters of from ten to twenty 
starch-granules, and some are visible to the naked eye. 

Barley-Water from Patent Barley-Flour. — No starch-gran- 
ules, but homogeneous starch material, together with abund- 
ant cellulose detritus, slightly finer than above. 

Barley-Flour Mixed With Cold Water. — Starch-granules 
and cellulose detritus, some visible to the naked eye. 

Wheat-Flour, Boiled. — Broken starch-granules and homoge- 
neous starch material. Clusters of swollen starch-granules in 
cellulose sheaths and cellulose detritus. 

Wheat-Flour Mixed With Cold Water. — Starch-granules 
free and in clusters, with envelope of cellulose. 

Rice-Wat er Made from the Grain. — Starch-granules broken 
down and in solution. There is some cellulose, but it is not 
so coarse nor as abundant as in barley or wheat. 

Arrowroot Mixed with Cold Water. — Starch-granules free 
from foreign admixture. 

From the above it will be seen that the blandest solution 
on which the infant can be fed is arrowroot water, after which 
comes rice-water. Wheat and barley both contain too much 
cellulose, particularly barley. In health this is no disadvan- 
tage, but under abnormal conditions it must be taken into 
consideration. 

Charcot- Ley den Crystals. — The flat, needle-like crystals 
first discovered in the sputum of patients suffering with bron- 
chial asthma are also found in the fseces quite constantly in 
cases of anchylostomiasis. Not so constantly, but quite fre- 



192 DISEASES OF CHILDREN. 

quently, they are encountered in association with tape- worm, 
ascarides, oxyurides and in amoebic dysentery. (Amberg; 
Simon.) On account of their close association with eosino- 
philic leucocytes they have been termed leucocytic crystals. 
These leucocytes and their free granulations can be demon- 
strated in such fecal matter by staining with eosin. 

Blood and Pus. — Blood and pus-corpuscles are at times 
found in the faeces when the naked eye does not suspect their 
presence. In such cases it is well to stain for tubercle 
bacilli, as tuberculous ulceration may be the source of these 
elements. It has been stated that the bacillus acidophilus of 
Moro possesses staining properties similar to Koch's bacillus, 
but I have not been able to satisfy myself that mistakes in 
diagnosis could thereby arise. 

Parasites. — In the faeces of children under mixed feeding, 
Pagliari (Jahresbericht iiber Thiercheniie, 1894) found the 
eggs of parasites in 90 per cent, of cases. They represented 
ascarides, trichocephalus and taenia solium. The eggs of the 
oxyuris are not found in the stool. The trichomonas is a 
protozoon of spindle-shape, with four flagellar at its anterior 
pole, and is of no pathological significance. It is thought to 
be identical with the trichomonas found in the vagina and in 
the urine. In examining for parasites and ova it is well to 
add a drop of Grassi's fluid (aqueous solution of iodine with 
potassium iodide) to the fecal matter. 

Amceb.i Coli. — This organism was discovered in the stool 
of dysentery patients by L,6sch in 1875, but its true relation 
to the disease was first established in 1885 by Kertuiis. In 
America, Osier was the first to demonstrate the amoeba in an 
hepatic abscess complicating amoebic dysentery. 

Amberg {Johns Hopkins Hospital Bulletin, December, 
1 90 1) reported five cases of amoebic dysentery in children 
ranging from three to five years. The amoeba are motile and 
contain red blood-corpuscles. They may be stained with a 
watery solution of toluidin blue, which does not kill them 
for from three to four hours. If the amoebic movements are 
not discernible, the slide should be warmed. 



DISEASES OF THE INTESTINES. 193 

Helminthes. — Oxyurides can often be obtained by means 
of the rectal tube, but their eggs are not deposited in the 
faeces. The eggs are smaller than those of the ascaris and 
are oval in shape. The ascaris deposits the eggs directly into 
the intestine. They are yellowish-brown in color, almost 
round, from 0.05 to 0.07 mm. in diameter, and surrounded by 
an irregulart albuminous shell. (See illustrations under 
u Intestinal Parasites"). 

The ova of the Uncinaria Americana (hook-worm) are illip- 
soids, 64 to 76 micromillimeters long by 36 to 40 broad, in 
some cases partially segmented, in others containing a fully 
developed embryo. Their color is grayish, like that of a 
steel engraving. (Stiles, Bull. No. 10, Hyg. Lab. U. S. Pub. 
Health and Mar. Hosp. Serv., Washington, February, 1903.) 

Tcznia saginata has elliptical ova of a brownish color with 
a distinct vittelline membrane. A double contour and striae 
may be demonstrated under high magnification. Tcsnia 
solium is rare in this country. The ova are surrounded by a 
thick, striated membrane, and the hooklets of the embryo can 
be seen within the ovum. 

The Bacteria of the Intestinal Tract. — The normal bacteria 
of the intestinal tract are represented chiefly by the bacillus 
lactis aerogenes and the colon bacillus. The former is found 
mainly in the upper intestinal tract, while the latter pre- 
dominates in the large intestine. The duodenum is compara- 
tively free from bacteria under perfectly normal conditions. 
The bacillus lactis aerogenes disappears from the stools as 
soon as the milk diet is dropped. Moro has described a 
bacillus which he calls the bacillus acidophilus, and which, 
according to his investigations, normally exceeds all other 
micro-organisms in the stools of breast-fed infants. He has 
isolated it from the nipple of the human breast and from the 
milk. Under abnormal conditions it becomes diminished and 
the colon group predominates. The chief characteristic dis- 
tinguishing it from the colon bacillus (including the typhoid 
bacillus and Shiga's bacillus) is the fact that it does not 
decolorize by Gram's method. 



194 DISEASES OF CHILDREN. 

By Escherich's stain it therefore stains blue, while the 
colon group is stained red. Bscherich (Die Darmbacterien 
im Sauglingsalter, 1886) was of the opinion that under nor-- 
mal circumstances most of the colon bacilli resisted the Iodine 
solution and did not lose their stain, while in diarrhceal affec- 
tions they were decolorized. This view, however, has been 
controverted by Moro's investigations. (Wiener Klinische 
Woch., No. 5, 1900.) 

Nevertheless, Escherich's stain is of the greatest practical 
importance, as it demonstrates the exact proportion between 
normal and abnormal bacteria in the infantile stool. It is 
carried out as follows : 

A cover-glass preparation of the stool is fixed in the flame 
of a Bunsen burner and stained for a few seconds with 
aqueous gentian violet plus aniline oil and blotted ; it is then 
immersed for a few seconds in aqueous Iodine solution and 
blotted ; decolorized with a mixture of equal parts aniline oil 
and xylol, washed in xylol and dried. The specimen is now 
counter-stained with alcoholic fuchsin, washed with water, 
dried and mounted in Canada balsam. The formulae for the 
stains are : 

1. Aqueous solution of gen tain violet, 5 : 200. Boil for 
half an hour and filter. 

2. A mixture of absolute alcohol and aniline oil in the pro- 
portion of 11:3. 

3. Mix No. 1 and No. 2 in the proportion of 85: 15. This 
represents the stain, which will only keep for two or three 
weeks. 

4. A solution of Iodine, one part ; Potassium iodide, two 
parts ; water, sixty parts. 

5. Concentrated alcoholic solution of fuchsin, diluted with 
an equal volume of absolute alcohol. 

With this method, normal and abnormal stools can even be 
distinguished macroscopically, by the preponderance of the 
blue color in the former and the red in the latter. When 
streptococci are present, as is the case in grave inflammatory 






DISEASES OF THE INTESTINES. 195 

lesions of the intestinal mucosa with resulting infiltration and 
necrosis of the tissues, they retain the blue color, but are 
readily distinguished from the bacilli by their form 

While the colon bacillus and the bacillus lactis serogenes 
are normally saprophytes, still it has been clearly proven that 
both, especially the colon bacillus, may, under certain condi- 
tions, assume pathogenic properties. 

The proteus vulgaris is often found in the stools of arti- 
ficially-fed infants, and when active produces a foul odor. It 
is usually regarded as non-pathogenic. The chief interest at- 
tached to it is that at one time pure cultures were used for 
therapeutic purposes, as it was found that the colon bacilli 
could not exist side by side with the proteus. 

It is characterized by its variable forms and is decolorized 
by Gram's method. 

Shiga's Bacillus. — Since the investigations of Duval and Bas- 
sett at the Thomas Wilson Sanatorium in Baltimore, during 
the summer of 1902, which resulted in the surprising discovery 
that the bacillus dysenterise of Shiga was the etiological factor 
in the series of cases of summer diarrhaa under observation, 
this organism has come to occupy the most prominent role in 
the bacteriology of the intestinal tract of children. Duval 
had previously been engaged in studying the acute dysenteries 
of adults under Flexner, of the University of Pennsylvania, 
and his work was therefore immediately accepted as authentic. 
In an address before the medical association of New York 
City (October, 1903), Flexner commented upon the work of 
Duval and Bassett, stating that while these investigators were 
not prejudiced in the belief that the bacillus of Shiga was a 
distinctive germ of summer diarrhoea, still all other organ- 
isms present resisted the test applied to them. Cultures were 
made and the agglutination test employed. In over forty 
cases was the bacillus isolated. Since then the Shiga bacillus 
has been isolated repeatedly from the stools of children suf- 
fering with acute diarrhoea, both here and abroad. 

The bacillus is a short rod with rounded ends, and is 



196 DISEASES OF CHILDREN. 

slightly motile. Vedder and Duval claim to have demon- 
strated flagellar It does not produce spores, and, like the 
other members of the colon group, decolorizes by Gram's 
method. Like the typhoid bacillus, it possesses distinct ag- 
glutinating properties with the diluted blood serum from an 
infected individual. On the strength of this fact it was hoped 
that a curative antitoxic serum might be evolved. Its growth 
is slower than that of the colon bacillus, and in a soft jelly it 
forms a perfectly spherical colony, while the typhoid bacillus 
forms threading colonies, and the colon bacillus a collection of 
small colonies. It is more difficult, however, to distinguish it 
from the paratyphoid bacillus. (Dunham, N. Y. Med. jRecord, 
Feb. 28, 1903.) 

It is best isolated as follows : Grow on agar plates at 37 ° C, 
and mark with a pencil the colonies appearing at the end of 
twelve hours. These are usually colon bacilli. The ones ap- 
pearing later should be transplanted to glucose-agar fermenta- 
tion-tubes in order to differentiate the gas formers. The ag- 
glutination reaction is possible with a i-to-50 dilution of the 
blood serum of the patient afflicted. In fresh bouillon cul- 
tures the bacillus is motile during the first eight to twelve 
hours. It has but slight resistance to heat and antiseptics. 
(Muir and Richie, Manual of Bacteriology, 1903.) 

SIMPLE DIARRHOEA; ACUTE INTESTINAL INDIGESTION. 

I 

Etiology.— Owing to the functional and structural pecul- 
iarity of the stomach in infancy, the main work of digestion 
is thrown upon the intestinal tract, and for this reason intes- 
tinal disturbances are relatively more frequent than gastric 
during this period. Even in the case of gastric indigestion 
diarrhoea is usually a secondary manifestation, owing to the 
entrance of the unsuitable or excessive quantity of food into 
the intestines when not promptly vomited. Although the 
dyspeptic variety of diarrhoea is the most frequent form en- 
countered, and, as has been said before, is due to overfeeding 
or to the use of improper food, such as breast-milk too rich in 



DISEASES OF THE INTESTINES. 197 

proteids or fat, or vitiated by maternal ill-health, and in the 
case of hand-fed infants, the use of insufficiently-diluted cow's 
milk, swill milk, starchy food in early infancy, etc., still there 
are other influences capable of inducing a looseness of the 
bowels, to which belong mechanical irritation from the inges- 
tion of a foreign body or irritating substances and nervous in- 
fluences, such as chilling of the surface of the body, hot 
weather, fright, dentition and idiopathic irritability of the in- 
testinal tract. 

Predisposing factors are important; among them are pre- 
vious attacks of intestinal catarrh, anaemia, chorea, malnutri- 
tion, rickets, tuberculosis and syphilis. Physiological predis- 
position is most active during infancy; pathological during 
childhood. 

Symptomatology. — The cardinal symptoms are colicky 
pains, flatulence and dyspeptic stools. Moderate fever is 
usually present. The early symptoms are pain and flatulence, 
with an increase in the number of stools. The number is 
seldom greater than five to six daily, and the watery element 
and amount of mucus are not increased, but there is present 
undigested food in considerable quantity, and in the case of a 
milk diet, white flakes consisting chiefly of fat. Curds of 
casein are often present, but not to the extent of the fat, and 
are distinguished from the latter by their tougher consistency 
and insolubility in alcohol and ether. At times the percent- 
age of fat in the stools reaches as high as 50 per cent, and over, 
in which case it is known as fat-diarrhoea (Demme ; BiEDERT). 
In case of excessive proteids the color is generally green. The 
green color is due to the presence of biliverdin. 

The "spinach and eggs" appearance is due to the inter- 
mixing of the fat flakes with the yellow and green elements 
of the stool. Beside the biliary, a bacillary green diarrhoea 
is recognized, in which the color is produced by a chromo- 
genic bacillus, and which is supposed to be more prevalent in 
the later period of infancy than the former (Le Sage). 

The duration is short and fever is slight or altogether ab- 



198 DISEASES OF CHILDREN. 

sent. Should the condition, however, become prolonged 
through|neglect of proper hygienic methods and lack of med- 
ical attention, the foundation for the development of rickets 
is laid. Fat-diarrhcea in its aggravated form often proves 
fatal, owing to its dependence upon serious pancreatic or 
hepatic disease. Demme reported nine such cases. 

Diagnosis. — The short duration, the inconsiderable fever or 
absence of fever, and the character of the stools differentiate 
simple diarrhoea from cholera t infantum and enter o-colilis. 
Neither are the watery elements markedly increased, as in 
the former, nor do we find present abnormal quantities of 
mucus and other constituents, such as blood and round cells, 
frequently found in the latter. The characteristic color and 
the presence of undigested food particles are the pathogno- 
monic symptoms. In hot weather infants commonly have 
watery, yellowish stools due to the enervating effect of heat 
and humidity upon the nerves controlling the secretions and 
movements of the intestines. 

The bacillary form is differentiated from the biliary by add- 
ing Nitric acid, which decolorizes the former and changes the 
latter to violet. The transition of a simple diarrhoea into an 
inflammatory or choleraic affection may take place. 

The diarrhoea ushering in some of the acute infectious fevers 
can only be indentified by the ultimate appearance of the 
symptoms peculiar to the affection in progress. 

Treatment. — Based on our knowledge of the predisposing 
and exciting causes of simple diarrhoea, the treatment must 
be mainly dietetic. Starchy foods, excepting in weak solu- 
tion, such as barley water, or in dextrinized form, should not 
be administered until the function of the salivary glands and 
pancreas has become well established, which is not before the 
sixth month, and is indicated by the eruption of the teeth. 

Infants whose digestive powers are naturally weak should 
be put on a milk-diet whose formula shall closely approxi- 
mate human milk in composition ; in some instances it may 
even be necessary to reduce one of the component parts of 



DISEASES OF THE INTESTINES. 199 

the formula below this percentage, as indicated by the symp- 
toms. When the proteids are not properly digested there 
will be vomiting of curds and the presence of the same in 
the stool ; the fat may also be found in the stool in excess, or 
produce vomiting. Flatulence points to fermentation of the 
sugar. The usual mistake is to begin with a milk too highlv 
concentrated, thus entirely upsetting the infant's digestion. 
It is always better to begin with a weak milk and gradually 
increase the strength. 

In breast-fed infants it may become necessary to analyze 
the mother's milk, and regulate her diet and exercise accord- 
ing to the indications thus furnished. Regularity in feeding 
must be insisted upon. 

During an attack it is advisable to withhold the usual food 
for twelve to twenty-four hours, as necessary, and administer 
simply boiled water, albumen-water or a thin barley-water; 
then sterilized milk and lime-water (barley-water three parts, 
milk one part, lime-water one part) may be tried. 

In the diarrhoeas accompanying teething, or those of a 
neurotic type, such remedies as Aconite, Belladonna. Chamo- 
milla, Gelsemium, the Calcareas and Pulsatilla are the ones 
usually indicated. In fat-diarrhoea Pulsatilla, Hepar and 
Magnesia card, have proven most useful in my hands. . 

In the class of cases in which the intestinal tract seems up- 
set by the food, Nux vomica and Lycopodium are most valu- 
able remedies. They are the remedies recommended bv 
Hughes {Manual of Therapeutics), and I can vouch for their 
usefulness. In the non-inflammatory cases, Nux in low dilu- 
tion; where enteritis has been set up, Lycopodium 30th 
(Hughes). 

Mercury I prefer to Lycopodium in diarrhoea when there is 
an abundance of mucus. Mercurius vivus 3X trit. will check 
most cases of diarrhoea promptly. When the stools are grass 
green Merc, dulcis is better indicated. China is useful in the 
diarrhoea of hot weather. 

Aeon. — In the beginning; after exposure to cold or during 
hot weather; thirst, fever and restlessness. 



200 DISEASES OF CHILDREN. 

Ars. — Diarrhoea after ice water, ice cream, etc.; usually 
with neuralgic pains in abdomen. 

Aloes. — Flatulence and rumbling in lower bowels; large 
quantities of gas escape with stool. 

Bell. — During hot weather and dentition; face flushed, ab- 
domen distended, colicky pains; cerebral symptoms; skin 
more moist, and child less restless than in Aeon. 

Bry. — Sudden changes in the weather, especially when 
there are hot days and cold nights. Diarrhoea worse morn- 
ings, painful, aggravation from motion. 

Calc. carb. — Dentition ; vomiting and diarrhoea. Stools 
grayish, chalky, offensive, undigested ; worse in afternoon 
and evening. 

Calc. phos. — Dentition delayed ; recurring attacks ; stools 
green, with flatus ; abdomen flaccid. 

Cham. — Dentition ; painful, excoriating diarrhoea, looking 
like spinach and eggs. Child cross and irritable. 

China. — Undigested stools ; flatulent colic, or painless stool 
with much fermentation. Anaemia and prostration ; loose 
yellowish stools in hot weather. 

Colocynth. — Pain relieved by firm pressure. 

Cupr. ars. — Diarrhoea, with abdominal pains and vomit- 
ing. Also when there are no special symptoms for any other 
remedy. — (Goodno.) 

Dulcamara. — During cold, damp weather. 

Gels. — Diarrhoea from fright, in older children of nervous 
temperament. 

Ipecac. — From unripe fruit, sweets, sour or fat articles of 
food ; vomiting, with coldness of extremities and pale face, 
even convulsions ; stools green as grass. 

Hepar. — Stooh white and foetid, or clay-colored {fat diar- 
rhoea) ; generally sour odor both of stool and child. Worse 
after eating and drinking cold water ; sour eructation ; 
hepatic derangements. 

Mag. carb. — Stools green and frothy, like frog-pond scum, 
containing tallow-like lumps. Sour odor ; colic relieved by 
stool ; fat-diarrhoea and lictitcria of sucklings. 



DISEASES OF THE INTESTINES. 201 

Mercurius. — " It is the better indicated the more widely is 
the departure from the natural color of the motions, and the 
more slimy they are." — (Hughes.) Diarrhoea with teething ; 
measles ; marasmus, etc. 

Nux vomica. — Acute intestinal indigestion. In the begin- 
ning before inflammatory reaction has been set up and the 
stools are composed of undigested food only. It corresponds 
to the stage in which Castor oil or Calo?nel is usually em- 
ployed to clean out the gut. 

Podophyllum. — Diarrhoea of changeable character, espe- 
cially as regards color. Usually thin and painless, with much 
gas. Prolapsus ani. 

ACUTE INFECTIOUS DIARRHCEA. 

Infectious diarrhoea differs from simple diarrhoea in the 
fact that micro-organisms play the most important role in its 
production. A simple diarrhoea indicates merely a disturb- 
ance in the peristalsis and intestinal secretion or in the 
chemistry of digestion. In infectious diarrhoea, however, w T e 
have to deal with either the direct action of germs or of their 
toxins upon the intestinal mucosa. 

Certain bacteria are capable of producing toxins in milk. 
When milk so contaminated is fed to an infant it will pro- 
duce an attack of cholera infantum, or acute milk-infection 
( Yavtghan). The ordinary putrefactive bacteria, notably, the 
proteus vulgaris and the colon bacillus, are the ones most active 
in this direction. Putrefactive changes may also take place in 
the gut, setting up similar symptoms. Under these circum- 
stances we speak of acute ferment al diarrhoea, or acute 
gastro-enteric intoxication (Holt). The bacillus lactis ccrogenes 
when present in abnormally large numbers is very apt to set 
up a fermental diarrhoea characterized by frequent, acid, foul- 
smelling stools. 

Lastly there are a number of bacteria that exert a specific 
action upon the intestinal tract, setting up ilco-colitis (inflam- 
matory diarrhoea) of varying intensity. It was formerly 
14 



202 DISEASES OF CHILDREN. 

taught, notably, by Escherich, that under abnormal condi- 
tions, especially favored by the action of continued hot weather 
and high humidity, the normal bacteria of the lower bowel 
{colon bacilli} acquired pathogenic properties and so set up an 
ileo-colitis. Streptococci were also found quite constantly 
associated with severe ileo-colitis by Booker, but as they were 
principally confined to the submucous tissues he rightly as- 
signed to them the role of a secondary infection. 

The most important step in advance in the bacteriology of 
ileo-colitis was made by Duval and Bassett, who in the sum- 
mer of 1902 isolated the Shiga bacillus from a considerable 
number of cases of summer diarrhoea in infants. Since their 
investigations the fact that the bacilli of dysentery are the 
specific organisms in the largest number of cases of inflamma- 
tory infantile diarrhoea seems to have been fairly w r ell estab- 
lished. Dyspeptic diarrhoea must, of course, be excluded 
from this category. 

The dysentery bacilli constitute a group, the most promi- 
nent members of which are the Shiga, or alkaline type, and 
the Harris, or acid type. The latter is the one that has been 
most frequently found. 

The dysentery bacilli may be looked for with practical cer- 
tainty where dysenteric symptoms are present, i. e., fever ; 
mucus and blood in the stool ; prostration. They are not, 
however, confined to any one type of pathologic lesion in 
the gut and may even set up choleraic symptoms as in a case 
reported by Booker. 

Among the predisposing causes to infectious diarrhoea//*:;/ 
weather stands pre-eminently. Indeed, so prevalent are these 
diarrhoeas in the hot months of the year that the popular ap- 
pellation, "summer-complaint," still clings to them. It may 
be said to be characteristic of gastro-enteric intoxication and 
ileo-colitis that they rage epidemically in July and August. 

Age is a strong predisposing cause. The majority of cases 
occur during the early tee tiling period, i. <\, from the sixth 
to the eighteenth month. This generally brings an infant 
born the previous year into its second summer. 



DISEASES OF THE INTESTINES. 203 

Food. The importance of food as an etiologic factor is only 
secondary to that of temperature and humidity. Children 
that are exclusively breast-fed rarely develop ileo-colitis and 
then probably only through lack of hygienic care. The 
fact that an infant is breast-fed does not exclude the possi- 
bility of its being infected if the nipples are not kept clean 
or if they are fissured. Again, ordinary filth and the drink- 
ing of contaminated water may be the source of infection. 
The vast majority of cases, however, are artificially fed with- 
out proper efforts being made at sterilization of bottles and 
nipples and with disregard for the source of the milk. It is al- 
ways the safer plan to use pasteurized milk in the summer. 
Cold weather seems to give a surprising immunity to diar- 
rheal affections even when the quality of the milk is none 
too good. The investigation of Holt and Park {Archives of 
Pediatrics, Dec, 1903) into this subject has shown the rather 
startling fact that despite the large number of bacteria 
that were found in many samples of milk fed to infants in 
the winter there was a remarkable tolerance for the same on 
the part of these infants. The practice of boiling milk and 
using pasteurized milk, now becoming more general among 
all classes, has done much toward reducing the infantile 
death-rate. 

The environment is an important factor. Fresh air and 
personal cleanliness are two of the strongest prophylactic 
measures in infantile diarrhoea and when infants are kept in 
squalid, poorly ventilated or crowded quarters and not 
regularly bathed they offer poor resistance to the invasion of 
a serious intestinal affection. Under such circumstances the 
feeding is also likely to be conducted in a most careless and 
dirty manner. 

Intestinal indigestion is often the first step in the clinical 
course of ileo-colitis and infants who are allowed to go on 
with such a condition, from faulty feeding and neglect, will 
sooner or later develop cholera infantum or ileo-colitis. Cer- 
tain constitutional diseases predispose to enteritis. They are 



204 DISEASES OF CHILDREN. 

notably rickets, syphilis and tuberculosis. Diarrhoea may be 
a terminal event in malnutrition, marasmus and tuberculosis. 
Certain of the acute infectious diseases are ushered in with 
diarrhoea (pneumonia, scarlet fever) or they become compli- 
cated with the same (measles, whooping cough). 

CHOLERA INFANTUM ; ACUTE GASTRO-ENTERIC 
INTOXICATION. 

Infection. — Cholera infantum isagastro-intestinal infection 
of great virulence in which the symptoms are of rapid onset 
and of a grave character, clinically resembling Asiatic cholera. 

The symptoms are the result of the absorption of toxins, 
which may already exist in the milk prior to its ingestion — 
acute milk infection. Vaughan has demonstrated that im- 
properly kept milk may be sufficiently toxic to produce 
choleraic symptoms in animals. Pasteurization or sceriliza- 
tion is of no avail under these circumstances, as the toxins 
are not affected thereby. 

Again, if unsterilized milk be fed in which the colon 
bacillus, or the proteus vulgaris, be present, decomposition 
may take place before digestion is completed and an acute 
ectogenous infection be the result. 

Booker {Archives of Pediatrics /Nov., 1903) cites an inter- 
esting case of summer diarrhoea of the cholera infantum type 
in which the child was greatly prostrated and slightly toxic, 
the stools being watery and putrid. He looked upon the 
condition as one of infection with the proteus vulgaris, but 
investigation proved it to be practically a pure Shiga bacillus 
infection. 

It is also possible that as a result of the enervating effects 
of long continued hot weather and high humidity in conjunc- 
tion with improper feeding, deficient ventilation, flatulent 
dyspepsia (Henoch), the micro-organisms already present in 
the gut, and benign under normal circumstances, may assume 
a virulent character and set up an endogenous infection. 

The majority of cases are encountered during the months 



DISEASES OF THE INTESTINES. 205 

of June, July and August ; this is especially so in large cities 
where the disease occurs epidemically. The hot weather acts 
both by lowering the infant's resisting powers and by interfer- 
ing with the proper keeping of the food. It is, therefore, 
plain to be seen why the most rigid supervision of the milk 
supply must be enforced and why the food should be pasteu- 
rized at this time of year. 

Age offers a predisposing cause ; infants are particularly 
susceptible during the second six months. This is a period 
when dentition is active and invites attacks of indigestion 
besides lowering the infant's vital resistance. The importance 
of this etiological factor must, however, not be over-estimated. 

On the other hand, cases will arise at any time of the year 
and in infants perfectly well to all appearances. The intro- 
duction of the poison into the system in sufficient amount is 
all that is necessary to precipitate the condition. 

Pathology. — Post-mortem appearances will depend upon 
the duration of the disease. In rapidly fatal cases an abnor- 
mal paleness of the mucous membrane of the stomach and 
intestines, with slight swelling of Pyer's patches and soli- 
tar}- follicles, is all that is to be seen. Booker found superfi- 
cial loss of epithelium of the mucosa of the stomach and gut, 
more or less extensive in distribution, in all fatal cases coming 
uuder his observation. The epithelium is infiltrated with 
leucocytes, as is also the submucous tissue. This infiltration 
may separate the epithelium from the underlying structure. 
The epithelial cells are cloudy and undergoing necrosis. The 
villi aud follicles may be ulcerated, and, if the condition has 
not proven too rapidly fatal, a beginning catarrhal enteritis 
can be demonstrated. In gastro-intestinal intoxication the 
course is more protracted than in cholera infantum and under 
these circumstances a distinct inflammatory reaction is set up. 
Micro-organisms, especially streptococci, are seen in large 
numbers in the mucosa in cases where the superficial epithe- 
lium has been exfoliated (Booker). 

Symptomatology. — Cholera infantum may begin as an at- 



206 DISEASES OF CHILDREN. 

tack of acute indigestion, or, what is more frequently the case, 
suddenly, with severe vomiting and copious dejections, high 
fever and rapid prostration. The temperature may be high 
from the beginning (104 F. and over), or it may be but 
slightly elevated during the entire attack. The food is 
promptly vomited, and later not even water or other bland 
substances are retained, or the vomiting may predominate 
over the diarrhoea. The dejections are yellowish-brown or 
green and fecal in the beginning, and usually painless, rapidly 
becoming more and more watery, until at last they consist 
entirely of serum. They are copious and occur from ten to 
fifteen times in twenty-four hours. 

Collapse results from the total depletion of the system, to- 
gether with the primary intoxication. With the collapse the 
hydrocephaloid state of Marshall Hall sets in, due to cerebral 
anaemia, with resulting venous hypersemia and oedema of the 
pia mater The child becomes somnolent and apathetic, the 
pulse thready or imperceptible, while the extremities are cold 
and cyanotic ; the eyes are half closed, sunken and surrounded 
by dark rings ; the cornea is lustreless and covered with shreds 
of mucus ; the pupils fail to react to light, the child falls into 
a stupor, and death supervenes, sometimes preceded by retrac- 
tion of the head and convulsions. The first symptoms men- 
tioned can be reconciled entirely with the circulatory disturb- 
ance present in these cases, i. e., fall of blood-pressure in the 
cerebral arteries, but when there is strabismus, retraction of 
the head and convulsions I am inclined to consider the 
condition, as viewed by Holt, Osier and other American 
writers, of toxic origin, especially as post-mortem findings 
are negative and as these symptoms are occasionally observed 
in other infections capable of inducing toxaemia. 

The urine is scanty, frequently contains albumin and may 
become entirely suppressed. Necrosis of the epithelium lin- 
ing the convoluted tubules is found at autopsy (Booker). 

Owing to the great loss of fluid the child suffers intensely 
from thirst, and toward the end of the disease sclerema may 



DISEASES OF THE INTESTINES. 207 

develop. This is a hardening of the skin, which begins in 
the feet and extends to the* gluteal region, sometimes also in- 
volving the back and upper extremities, due to resorption of 
the fluids and fat from the skin and subcutaneous tissue, with 
some evidence of thickening of the same. 

In severe cases a fatal issue ensues in the course of a few 
days; it may occur within twelve to twenty-four hours in very 
toxic cases. Where the heart's action can be sustained and 
the vomiting and* purging gradually subside, a favorable ter- 
mination may be looked for. The outlook, however, is always 
grave, cholera infantum being one of the most fatal dis- 
eases of infancy. The previous health of the child is of some 
value in gauging the prognosis as well as the mode of onset. 
A fulminating case naturally indicates a large initial dose of 
the poison. Breast-fed infants stand a better chance than 
those artificially reared. 

Diagnosis. — The condition with which cholera infantum is 
most likely to be confused is ileo-colitis. From this it must 
be differentiated by the rapid development of the symptoms, 
both the primary manifestations and those developing second- 
arily, i. e., the collapse, scanty urine and hydrocephaloid. 
The serous character of the stools is another diagnostic point. 

During epidemics of Cholera Asiatica bacteriological exam- 
ination of the stools would be the only positive test for differ- 
entiating the two conditions. 

Acute gastro-enteric intoxication is a ferment al diarrhoea, 
standing midway between simple diarrhoea and ileo-colitis. 
It is the commonest form of summer diarrhoea. The diar- 
rhoea is set up by the multiplication of bacteria in the intes- 
tinal tract, or in the milk prior to feeding, to such an extent 
as to induce chemical changes. The lower fatty acids — acetic, 
propionic and butyric — are particularly active in this direction. 
Products of nitrogenous decomposition may also develop in 
abnormal amount and induce diarrhoea. The bacillus lactis 
aerogenes is particularly concerned in the former (acid), while 
the proteus vulgaris and colon bacillus participate in the latter 



208 DISEASES OF CHILDREN. 

class of diarrhoea (alkaline), although a multitude of other 
bacteria may produce chemical changes in the intestinal con- 
tents. 

In mild cases the symptoms are those of intestinal indiges- 
tion. The fever, however, is higher and the stools more 
watery and frequent. At first they contain food particles, but 
later they become watery and of a dirty yellow or greenish 
color. The odor is exceedingly disagreeable and there is pain 
and flatus due to the fermentation. The stools usually pass 
with a loud, spluttering sound and have a frothy appearance. 
In the cases due to the oxidation of the carbohydrate and fat 
of the food the reaction is acid, while in those with proteid 
decomposition it is more likely to be alkaline, especially when 
serum is abundant. Mucus makes its appearance, but it is 
not as abundant as in ileo-colitis, nor is blood present. 

Severe cases act very similar to cholera infantum. They 
may begin abruptly with vomiting, temperature of 104 and 
over, purging, nervous symptoms and great prostration. As 
the intestinal canal becomes emptied, however, there is an 
amelioration of symptoms, and under proper management the 
case goes on to recovery. 

In a previously healthy infant the prognosis is more favor- 
able than in ileo-colitis or cholera infantum. 

The diagnosis rests upon the fact that we have here an in- 
toxication without anatomic lesions. A protracted case, how- 
ever, will set up pathological changes in the gut. From in- 
digestion it is differentiated by the more severe character of 
the symptoms, i. e., the more pronounced intoxication, the 
longer duration of symptoms (five to ten days) and the watery, 
offensive character of the stools. 

From ileo-colitis it is to be distinguished by the absence of 
characteristic pathological changes in the gut. The fever is 
not persistent, but falls after the second or third day ; there 
is no blood and only a small amount of mucus in the stools; 
pain, prostration and emaciation are less pronounced. 



DISEASES OF THE INTESTINES. 209 

ACUTE ILEOCOLITIS ; ACUTE INTESTINAL CATARRH; 
DYSENTERY. 

The term ileocolitis is usually adopted to designate the 
acute intestinal catarrhs of children, as in these cases the 
lower end of the ileum and the colon are more prominently 
affected than any other portion of the intestinal tract. Cases 
in which the colon and rectum are principally involved are 
described as dysenteric diarrhoea, from the distinct clinical 
picture they present. 

This term, however, has been abandoned, as it is but a 
variety of ileo-colitis. x\gain, when the stomach is involved 
in the inflammatory process we may speak of g astro-enteritis 
— a term still employed by some writers. 

Pathology. — Pathologically, we can divide ileo-colitis into 
acute catarrhal ileo-colitis ; acute membranous ileo-colitis 
{dysentery), and ulcerative follicular ileo-colitis. 

In mild cases the mucous membrane of the lower ileum and 
more or less of the entire colon appears congested and slightly 
swollen. In the small intestine the congestion usually ap- 
pears in streaks on the folds of the mucosa which are seen to 
run transverse to the long axis of the gut as it is laid open for 
inspection. The small intestine is distended with gas and 
filled with undigested food and greenish mucus, which ad- 
heres to its surface. The colon is more or less empty and in 
cases of short duration does not show as pronounced changes 
as the ileum, while in protracted cases it is always more 
affected. 

In more severe cases the deeper structures are involved, as 
a result of which there is slight thickening of the intestinal 
wall from round cell infiltration of the sub-mucosa. The 
lymphoid structures are also swollen from congestion and 
increase in the lymphoid cells and the congestion of the 
mucosa is more pronounced and uniform. In the small in- 
testine there is a distinct area of congestion about Pyer's 
patches ; the latter may stand out prominently, but they 



210 DISEASES OF CHILDREN. 

seldom ulcerate as in typhoid fever. The lymph-follicles of 
the colon are the ones most markedly involved and they 
stand out on the mucous membrane as small beads — -follicular 
enteritis. When the process has been a protracted one the 
follicles ulcerate. In severe catarrhal ileo-colitis ulceration, 
when it does occur, is more likely to take place irrespective 
of the lymph follicles and result in the production of variously 
sized, irregular, superficially situated areas (catarrhal ulcera- 
tion). Haemorrhage does not result from such ulcers but they 
offer a port of entry for the development of a general bacterial 
infection and they always tend to protract the case if they do 
not hasten the death of the child. 

Microscopically we find destruction of the superficial epi- 
thelial layer and more or less round- cell infiltration of the 
mucosa. The bloodvessels are engorged and the lymphoid 
structures swollen. In mild cases the process stops here. In 
severe cases the infiltration reaches to the muscular layers and 
necrotic changes take place in the inflamed follicles. The 
epithelium is densely infiltrated with leucocytes and more or 
less fibrin poured out. This is but a step to the membranous 
variety. 

Membranous colitis presents the most pronounced anatomic 
changes. It corresponds closely with dysentery as seen in 
adults, but the membrane is not so thick and ulceration does 
not occur so extensively. The membrane is practically limited 
to the colon, its ascending portion and the sigmoid flexure 
being favorite sites. The membrane is of a ditty-gray color 
and closely adherent to the mucous membrane, contrasting 
markedly with the deep red congestion of the latter where 
there is no membrane. The main changes are found in the 
intestinal wall, which is considerably thickened and rigid. 
Membrane may extend down as far as the rectum, where it 
can be seen during life as the child strains at stool. 

Follicular ulceration is not uncommon in cases that have 
run a protracted course. It is especially prevalent in institu- 
tions and among poorly nourished infants that have suffered 






DISEASES OF THE INTESTINES. 211 

from repeated attacks of gastro-enteric intoxication. The 
process is essentially a sub-acute one. Holt found it in thirty- 
six out of eighty-two autopsies upon infants dying of in- 
testinal inflammation. 

The appearance is characteristic. The ulcers are round, 
varying in size from a pin point to that of a split pea and re- 
present destruction and excavation of the inflamed solitary 
follicles. They may be found in both the ileum and colon, 
but most frequently they are confined to the colon. While 
they extend as deep as the muscular layer of the gut they do 
not tend to perforate. 

In association with the distinctive lesions of ileo-cclitis we 
not uncommonly encounter broncho-pneumonia as a complica- 
tion, which, in fact, may prove to be the determining cause 
of death in a protracted case. It is usually of the desqua- 
mative type ; rarely septic, although a general infection from 
the intestines is possible. 

In the kidneys we may find evidence of acute parenchy- 
matous degeneration. Actual nephritis is rare. The mesen- 
teric glands are usually enlarged. 

Symptomatology. — A case of mild catarrhal ileo-colitis 
begins with fever and loose movements ; intestinal fermenta- 
tion ; sometimes vomiting, and it cannot be distinguished from 
the non-inflammatory diarrhoeas until mucus and blood make 
their appearance in the stools. Instead of these symptoms 
abating after the intestinal tract has emptied itself we find 
rather an increment in the severity of the condition and the 
child continues to have small, frequent dejecta consisting in 
the main of mucus and a little blood. These stools are alka- 
line in reaction and practically odorless. 

As the case advances the stools become more irregular. 
Some are large, containing mucus, undigested food particles 
and serum in abundance while again others are simply a stain 
of mucus on the diaper as a result of the tenesmus that plays 
so prominent a role in ileo-colitis. On account of this 
straining there is a strong tendency to the development of 
prolapsus ani. 



212 DISEASES OF CHILDREN. 

The constitutional symptoms are fever of moderate grade, 
ranging between 99 F. and 102 ° F., although at the onset it 
may be much higher for a short period ; prostration ; loss of 
appetite and in some cases vomiting. The duration of these 
symptoms is about a week. Convalescence is slow and is 
characterized by a tendency to persistence or recurrence of 
mucus in the stools as soon as we attempt to put the child 
back on its customary diet. 

Severe catarrhal ileo-colitis presents symptoms much in 
common with, dysentery. Constitutional symptoms are pro- 
nounced. The fever is high throughout the entire course of 
the disease and the movements are frequent, accompanied by 
painful straining and consisting mainly of bloody mucus. The 
abdomen is not distended as a rule, but owing to tenderness 
it may be rigid. 

Prostration and nervous symptoms are marked. The child 
presents the picture of a severe infection — dry, coated tongue; 
sordes on the teeth ; apathy or great irritability ; anorexia and 
thirst ; prostration. Death from sepsis, broncho-pneumonia 
or exhaustion is a frequent outcome. If recovery takes place 
we may look for a protracted convalescence on account of ca- 
tarrhal ulceration of the gut. The duration is from two to 
three weeks, although death may occur in the first few days. 

Follicular ulceration is to be suspected in children of weakly 
constitution who have had repeated attacks of diarrhoea or a 
protracted moderately severe ileo-colitis and in whom mucus 
persists in the stools. There is also a combination of fever of 
moderate range. The accompanying symptoms are progressive 
emaciation and failure of strength ; anorexia ; bed sores ; 
thrush, etc. The duration is long ; the condition is practi- 
cally a sub-acute one. The course is marked by improve- 
ment and exacerbation and so may be protracted for two or 
three months. Even after the ulcers have healed there is 
more or less persistent indigestion and tendency to diarrhoea 
for some time. The characteristic symptoms may be summed 
up as continued loose movements, four to eight daily, consist- 



DISEASES OF THE INTESTINES. 213 

ing chiefly of greenish mucus ; slight fever ; emaciation ; ab- 
sence of biood in the stools. It is also to be remembered that 
follicular ulceration is the result of extension of the inflam- 
matory process into the deeper layers of the mucosa as a re- 
sult of repeated attacks of intestinal infection. It is, there- 
fore, almost always encountered in delicate or poorly cared 
for infants during the teething period. 

Membraneous Colitis. — Strange as it may seem, this severe 
form of enteritis often presents the most uncharacteristic 
symptoms ; indeed, we may be deceived into looking upon 
the condition as an entirely different disease. 

When the onset is abrupt and accompanied by cerebral 
symptoms it closely simulates meningitis. High fever ; con- 
vulsions ; retraction of the head and abdomen ; vomiting and 
stupor may be present for several days before our attention 
will be directed to the intestines by the appearance of bloody 
stools and possibly prolapsus ani. 

The majority of cases, however, simulate severe catarrhal 
ileo-colitis with the exception that shreds of membrane ap- 
pear in the stools and may be seen at times upon the rectal 
mucosa during prolapsus. In all doubtful cases the stools 
should be carefully washed and strained, as it is difficult 
to distinguish membrane from mucus when the latter is 
abundant. 

The duration is from one to three weeks. It is very fatal, 
especially in young infants; in older children its protracted 
course may lead one to suspect typhoid fever on account of 
the continued high pyrexia. 

The diagnosis rests upon the evidence of severe inflamma- 
tion of the large intestine, especially of the descending portion. 
Together with continued high fever and prostration there are 
frequent, small stools consisting mainly of blood and mucus 
and there may be shreds of membrane. There is tenderness 
along the entire course of the colon, but particularly along its 
descending portion. In typhoid fever tenderness is only found 
in the ileo-csecal region and the stools are large, consisting 
mainly of the contents of the small intestine. 



214 DISEASES OF CHILDREN. 

In meningitis the bowels are constipated and the cerebral 
symptoms progress in regular order from day to day. In 
dysentery they are purely toxic and therefore vary ; in fact, 
they may clear up, while the intestinal symptoms increase in 
severity. 

Pain, tenesmus, vomiting and prostration may suggest 
intussusception, but in this condition the onset is abrupt, there 
is no fever, and an abdominal tumor may be made out. 

Treatment. — Although the treatment of the infectious diar- 
rhoeas must have much in common with the entire group, 
still individual cases will require remedies and adjuvants 
peculiarly adapted to their characteristic symptoms. Prophy- 
laxis is of the greatest importance, and is equally urgent for 
all cases. In the first place, the exciting cause (micro- 
organisms) must be most rigorously combatted ; in no case 
should a child be fed on contaminated food, or allowed to 
nurse from bottles or nipples not aseptically clean. 

All discharges should be disinfected, as not infrequently 
diarrhoea becomes epidemic in a family or hospital ward. 

The supervision of the food is of the greatest importance. 
Use only pure, clean milk. Boil the water you give the babe. 
Pasteurization will not make dirty milk wholesome. If 
chemical changes have occurred in the milk, sterilization will 
not prevent it from acting as a poison. Another important 
point in prophylaxis is not to wean an infant during the 
summer. There are times when this becomes necessary, but 
whenever at all possible we should wait for the advent of cool 
weather before taking this step. 

Prophylaxis, therefore, resolves itself into regulating the 
child's surroundings and most rigorously attending to even- 
detail of feeding. In summer no infant should be kept in the 
city if the parents can afford to take it away. The country is 
good ; the seashore is better. Even after the infant is seized 
with ileo-colitis it is not too late to take it out of the city, 
and its recovery may depend upon this step. 

The poor and overcrowded are particularly unfortunate and 



DISEASES OF THE INTESTINES. 215 

foi them we have not sufficient charities to give them the 
cheapest of nature's offerings, — fresh air. Let them keep the 
children indoors all day in the coolest room, with the shutters 
closed in to keep out the broiling sunlight, and. after sundown 
and early in the morning take them out to the neighboring 
squares and parks for an airing. Trolley rides and trips on 
the river are fortunately cheap and will help to save many a 
baby's life. 

Bathing is most essential during hot weather. The cool or 
tepid bath is absolutely necessary when fever is present, and 
it may be given three to four times a day. Chapin recommends 
allowing the children to play in a bath tub partly rilled with 
luke-warm water. 

Even though we may be able to obtain milk that has been 
handled in the most careful, up-to-date manner, and we know 
it to be clean and reasonably free from micro-organisms, still 
I believe we are taking chances if we do not pasteurize it in 
hot weather. An error in the technique in the preparation of 
the infant's bottles at any one point of the process may result 
in a fatal case of ileo-colitis. 

The nipples should be boiled every day and the bottles 
filled with hot water and washing soda as soon as emptied. 
Then before refilling they should be cleansed with a bottle- 
brush and thoroughly rinsed with hot water. 

When maternal feeding is practiced the nipples should be 
washed before and after nursing with a saturated solution of 
boric acid. The infant should not nurse directly from a fis- 
sured nipple. Here it is better to employ a sterilized shield 
or pump out the milk and feed it with a spoon. These 
methods are preferable to attempting to cleanse an infant's 
mouth after nursing. 

In hot weather infants get thirsty between feeding times 
and should receive an ounce or two of water, previously 
boiled and then cooled. 

A most important point to bear in mind is that during hot 
weather an infant cannot, as a rule, take the same strength of 



216 DISEASES OF CHILDREN. 

fat and proteids it is able to digest at other times. It will 
■usually take the same quantity because it is thirsty, but un- 
less we cut down percentages we may set up a severe indiges- 
tion which in turn will invite enteritis. Do not expect a babe 
to make its regular weekly gain in weight during July and 
August. 

When diarrhoea has developed we must at once make 
material changes in the feeding. In a breast-fed infant, in 
the absence of fever and vomiting, we may for a day or two 
continue with the breast milk and wait for the action of our 
remedies. Should the condition not improve it will be well 
to alternate a bottle of barley-water with the breast and in 
that way give the digestive organs a rest. Should the condi- 
tion get progressively worse in spite of this we must stop the 
breast entirely. 

The reason milk is discontinued in diarrhoea of infants is 
because it acts as a good culture medium for the micro- 
organisms that are causing the trouble, and the curds of 
casein act as an irritant to the mucous membrane. In acute 
ileo-colitis milk, even if sterilized, is practically a poison. 

Barley-water as an all-round substitute food is, perhaps, the 
most generally useful one. It leaves very little residue in the 
gut and starves out the bacteria. Sometimes it disagrees or 
is objected to by the infant. I have previously pointed out 
that the particles of cellulose found in barley-water may irri- 
tate the inflamed mucous membrane. In such cases I use 
arrowroot, which is more bland and more acceptable to some 
infants. In protracted cases the infant will lose too much 
flesh if we only give it barley-water, and as milk may have to 
be withheld for several weeks in isolated cases, particularly 
when there is follicular ulceration, we must use a more nour- 
ishing milk substitute. Here I like to alternate lamb-broth 
made with rice and then strained, and barley-water containing 
half-ounce of sugar of milk and the white of one egg to the 
pint. The twice-boiled flour-ball is another excellent food, 
especially for very young infants. A return to milk must 






DISEASES OF THE INTESTINES. 217 

be made cautiously, beginning with low percentages, especi- 
ally of proteids. A tablespoonful of milk to four ounces 
barley-water is a safe beginning. Sometimes it will be found 
beneficial to restrict cases with alkaline stools exclusive!}* to 
carbohydrates and those with acid stools to broths. 

Special Symptoms and Their Management. — Vomiting is 
at times a most troublesome complication, especially in chol- 
era infantum. Lavage of the stomach is the most rational 
and successful method of treatment to control it. In urgent 
cases it may be necessary to perform the operation several 
times a day, and then pour a little food into the stomach be- 
fore removing the tube. Thin arrowroot-water or albumin- 
water is best retained under these circumstances. 

Often the food will be retained better if fed with a teaspoon 
than wdien taken from a bottle. When the infant can take 
only a small quantity of food at a time we must feed it often, 
but there is no good in feeding every five or ten minutes, as 
is sometimes done. 

Diarrhcea. — In the early stages of an intestinal infection 
we will derive much benefit from bowel irrigation. It is rare 
that the gut thoroughly empties itself at once, and if the ab- 
normal intestinal contents are allowed to remain undisturbed 
for any length of time inflammatory changes in the intestinal 
mucosa will result. It is true, the irrigating fluid does not reach 
beyond the ileo-caecal valve, but, as the colon receives the 
brunt of the attack in most instances, we help the case mate- 
rially by cleansing this part of the gut. Besides, irrigation 
stimulates peristalsis, and thus aids in emptying the portion 
of gut above this point. 

We often encounter a condition of high fever with frequent, 
small stools, consisting chiefly of mucus and a little blood. 
The abdomen is distended with gas and the gut laden with 
decomposing fecal matter. Here irrigation is imperative. In 
such cases mild, cautious purgation is justifiable, but I must 
warn against the indiscriminate and injudicious use of the in- 
itial Calomel purge. I can recall several cases in which ever}- 



218 DISEASES OF CHILDREN. 

chance of recovery was spoiled by the superadded irritation 
induced by Calomel. 

Persistence of mucus in the stools calls for irrigation, but 
we must stop this procedure as soon as the bowel begins to 
empty itself naturally. Many a diarrhoea is kept up by too 
much mechanical interference. 

When tenesmus is persistent we can give the child much 
relief by injecting a small amount of warm olive oil into the 
rectum. This exerts a soothing influence upon the inflamed 
membrane. 

High fever is best controlled with the bath. Infants may 
be tubbed two or three times daily in water gradually reduced 
from 90 F. to 8o° F., while older children are more conveni- 
ently sponged with cold water and alcohol. Irrigation also 
tends to control the pyrexia. The child should be kept in 
the open air as much as possible. 

Collapse requires active stimulation. Brandy should only 
be used when called for, and not given continually during the 
illness. In grave cases a hypodermic injection of camphor- 
ated oil may be necessary. Five minims may be given to an 
infant one year old. Camphor suits this condition admirably, 
and it is best given hypodermically, as it may otherwise irri- 
tate the stomach. Most cases of cholera infantum will need 
it sooner or later. Artificial heat must be applied also when 
the body surface becomes cold or the temperature subnormal. 
I have at times seen beneficial results from hypodermoclysis. 
injecting an ounce or more of normal saline solution into the 
abdominal subcutaneous tissue with an antitoxin syringe. 
These cases are so grave, however, that often nothing will do 
the slightest good. 

Remedies. — While each case should be individually pre- 
scribed for, still we can more or less successfully classify our 
remedies in accordance with their applicability to the differ- 
ent varieties of infantile diarrhoea. 

In simple intestinal indigestion Nux vomica is most useful. 
When given in time it will often cut short an attack. Hughes 



DISEASES OF THE INTESTINES. 219 

recommends Lycopodium when the condition becomes inflam- 
matory. Teste speaks of this remedy as a specific in infantile 
enteritis. 

Some infants are predisposed to diarrhoea without any ap- 
parent cause. In these cases there seems to be a slight ca- 
tarrh, such as we find in the respiratory tract. Pulsatilla is 
very valuable here. The diarrhoea accompanying teething is 
especially benefited by Chamomilla. In acute gastro-intestinal 
intoxication Belladonna appears most frequently indicated on 
account of the predominance of fever and nervous symptoms. 
Even in the later stages, when the bowel symptoms become 
more prominent, I have found Belladonna invaluable as long 
as fever and toxaemia were present. 

In the ordinary case of fermental diarrhoea and ileo-colitis 
I find Podophyllin 2x trit. a good routine remedy. Mercurius 
virus 3X trit. follows, if ulceration takes place. This is 
indicated by the continuance of the diarrhoea, moderate fever 
and abundant mucus in the stools. In the dysenteric type of 
colitis, Mercurius corrosivus 6x is the chief remedy. 

Arsenicum, Ipecac and Veratrum album are the most useful 
remedies in cholera infantum. Veratrum is Jousset's favorite. 
Iris versicolor w r ill check the vomiting speedily, but leaves 
the bowels untouched according to Richard Hughes. Arsenic 
and Veratrum are often difficult to differentiate, especially in 
the beginning of the case. Under these circumstances there 
is no objection to alternating. I have often found that when 
one of the apparently indicated remedies failed to act, prompt 
improvement followed on giving a constitutional remedy in 
alternation. Among these Calc. phos. stands foremost. 

Goodno cites a remarkable result obtained from the use of 
Zincum 6x trit. in a case of collapse with abolition of all 
reflex excitability, together with a cessation of vomiting and 
diarrhoea. For a more detailed study of the therapeutics of 
diarrhoea the following remedies are appended : 

Aeon. — In the beginning ; high fever and restlessness ; 
green mucus in the stools. 



220 DISEASES OF CHILDREN. 

Aithusa. — Vomiting of large curds, followed by prostration ; 
projectile vomiting ; convulsions. 

Antimon. crud. — Tongue heavily coated white ; disposi- 
tion much changed, making the child disagreeable and 
fretful. 

Apis. — Cerebral symptoms; suppression of urine; coma, 
with hot head, dry skin ; shrill cry. 

Arsen. — Watery stools, with vomiting and collapse ; stools 
offensive, first greenish, later becoming dark or brownish, 
acrid ; also small mucus stools with tenesmus. Child nurses 
often, but takes only a small quantity at one time. Mainly 
differentiated from Veratrum album by concomitant symp- 
toms, although where Arsenic is indicated pathological 
changes have already occurred in the bowels, blood and 
viscera. The symptoms are violent from the beginning, or, 
if less acute, are marked by a progressive downward tendency. 

Bell. — Green stools, abdomen distended and sensitive ; face 
red, high fever. Where inflammatory symptoms are pro- 
nounced Belladonna is the most important remedy, especially 
when brain symptoms make their appearance. 

Bry. — Brought on by change of weather ; stools brownish, 
worse from motion ; great thirst for large quantities of water. 

Calc. carb. — Stools light in color, sour odor ; sour vomit- 
ing ; dentition ; rachitic tendency ; belly large. 

Calc. phos. — Child looks old, under-developed ; stools green- 
ish, thin and offensive; history of tardy dentition; belly 
flabby. A most valuable tonic both during the disease and 
in convalescence. 

Carbolic ac. — When the vomiting is a distressing feature, 
two or three drops in half a glass of water, half teaspoonfnl 
every half hour. — (Chas. D. Crank.) 

Camphor. — Sudden appearance of choleraic symptoms; 
great prostration and collapse ; body cold, apathetic state; will 
not remain covered. 

Cham. — Stools green, with white particles, looking like 
" spinach and chopped eggs ; n fretful ; one cheek red, the 
other pale ; child wants to be carried about. 



DLSEASES OF THE INTESTINES. 221 

China. — Undigested stools; movements watery and yellow; 
much distension of abdomen and colicky pains. China acts 
as a tonic in protracted cases. 

Colocynth. — Painful cases ; pressure gives relief. 

Croton tig Hum is a remedy I have frequently used 
with marked success in gastro-enteric infection where the 
stools are profuse and watery and of a yellow color The 
mother will also tell you that every time the child takes its 
bottle it has one of these movements, drinking apparently ex- 
citing peristalsis and bringing on a stool. It is distinguished 
from Podophyllum by a less amount of gas and mucus and 
absence of straining. 

Cupr. ars. — Painful cases ; choleraic and convulsive symp- 
toms predominate. 

Ferrum phos. — Dr. E. L. Clark, of Media, Pa., has called 
my attention to the value of Ferrum phos. in the early stage 
of ileo-colitis when there is high fever and blood-streaked 
mucus in the stool. 

Ignatia. — Prolapsus ani ; cerebral symptoms developing 
suddenly. 

Ipecac. — Nausea and vomiting ; stools green as grass, or 
like yeast. Early stages of cholera infantum. 

Iris. — This remedy has yielded excellent results in cholera 
infantum, but is also useful for other diarrhoeas accompanied 
by vomiting. The vomited matter is sour, the dejections are 
thin and tinged with bile. 

Mag. carb. — Sour diarrhoea and vomiting; stools green, like 
frog-pond scum (fermentation). 

Mag. sulph. — Dr. Frank H. Pritchard {Hahnemannian 
Monthly, Nov., 1900) reports favorable results from the use 
of a weak solution of the Sulphate of Magnesia in the sum- 
mer diarrhoeas of children. His dosage is one-half to one 
grain dissolved in a teaspoonful of water. The indications 
calling for it are copious, watery stools, deficient in bile. He 
noted that as soon as the remedy had begun to act favorably 
the stools became bile-tinged. Podophyllin has a similar 
action. 



222 DISEASES OF CHILDREN. 

Mercurius. — A predominance of mucus and involvement of 
the rectum calls for Mercury. The Bichloride is often prefer- 
able to the metal in dysentery ; Calomel has grass-green stools. 
The " never-get-done " feeling of Merc. sol. is very character- 
istic, while the Bichloride has tenesmus of the bladder as well 
as rectum, and is the chief remedy in membranous colitis. 

Podophyllum. — Painless, yellowish or greenish, water diar- 
rhoea ; prolapsus ani. As a routine remedy, I must acknowl- 
edge Podophyllin 2x trit. as the one most generally useful. 
When the stools are thin and greenish, expelled with consid- 
erable gas — an indication of fermentation — this remedy should 
be pushed until the normal yellow color reappears and the 
consistency is changed to a more pasty character. 

Sulphur. — Excoriating stools, worse mornings ; marantic 
cases. The child is peevish and has a voracious appetite. 
The lips are very red and the anus become excoriated. Un- 
healthy condition of the skin. "It is especially useful in 
dysentery after Aconite has removed the acute symptoms, 
when the tenesmus has ceased but blood is still discharged." 
(Bell). 

Veratr. alb. — Vomiting and purging, the latter most prom- 
inent ; motion aggravates all symptoms ; cold sweat on fore- 
head. There is less prostration and thirst than under Arsen- 
icum, less restlessness and usually more pain, and when any 
doubt exists as to a choice between the two, Veratrum should 
receive the preference early in the case. When Arsenicum 
becomes indicated the patient has passed into a state of pro- 
found exhaustion, from which it is difficult to recall him. 

Dysentery. — Aloes, Apis, ars., Baptisia, Bell., cantharis, 
Capsic, Colch., ipecac, Kalibichr., Lach., MERC, MERC. CORR., 
Nux vom., rhus Tox. 

Hydrocephaloid. — sElhusa, apis, ars., Bell., Borax, Br v., 
CAMPH., Chi?ia, CUPR., HE1XEB., Ignatia, I cratr. alb., ZINC. 

AMOEBIC DYSENTERY. 

Normally amoebae are never found in the stools of children ; 
rarely monads are encountered. Amoebic dysentery is uncom- 



DISEASES OF THE INTESTINES. 223 

mon in children, but the fact that Amberg {Johns Hopkins 
Hosp. Bull., Dec, 1901) met with five cases in his clinic 
(Baltimore) in a single winter indicates that the disease at 
least merits attention. Amberg's contribution on this subject 
is not only most thorough and comprehensive, but at the same 
time brings out most valuable data upon the state of the 
blood. 

The disease is contracted by drinking contaminated water. 
Well-water may be such a source, or children will drink water 
from the gutter, as in two of Amberg's cases. 

The course is chronic and usually of moderate intensity 
(Councilman ). The general health is not much disturbed, 
although the child becomes anaemic. The main symptoms 
are intestinal, i. e., pain and discomfort in the bowels; two to 
five loose stools daily with tenesmus, the stools containing 
mucus and more or less blood ; slight fever, not necessarily 
continued. Complications are rare. Abscess of the liver, 
however, has been encountered. 

In the stools motile amoeba, characteristically containing 
red blood-corpuscles, are found. 

Anaemia, more due to a deficiency in haemoglobin than to 
a reduction in the number of red corpuscles, results. Leu- 
cocytosis is present. The polymorphonuclear neutrophiles 
and the eosinophils are increased. When the anaemia be- 
comes pronounced megaloblasts and microcytes; polychro- 
matophilic erythrocytes and poikilocytosis may be encoun- 
tered. Myelocytes were also seen in severe cases (Amberg). 

chronic diarrhoea; chronic gastro-intestinal 
catarrh or mucous disease. 

Chronic intestinal catarrh may result from an acute attack, 
or it may be the outcome of a constitutional dyscrasia, such 
as scrofula, rickets, tuberculosis, anaemia, etc. Some of the 
infectious fevers are very prone to be followed by a more or 
less chronic diarrhoea, notably measles and whooping-cough, 
especially the latter, after which the so-called mucous disease 



224 DISEASES OF CHILDREN. 

frequently sets in. A physiological predisposition to excess- 
ive secretion of mucus from the alimentary tract belongs to 
childhood. There is no evidence that simple chronic catairh 
of the gut is necessarily of bacterial origin. No doubt a dis- 
turbance in the innervation of the secretory glands underlies 
a large number of cases, and it is reasonable to suppose that 
the debilitating influence of an infectious disease may readily 
cause such a disturbance. 

Pathology. — The pathological process is not confined to 
any particular locality in the intestinal tract, and may affect 
both the large and small intestines with equal severity. The 
mucous membrane presents a grayish appearance, with areas 
of injection. The solitary follicles are enlarged, and usually 
ulcerated. This results from secondary infection. Mucus is 
present in abundance, and infiltration of the submucosa with 
leucocytes, together with dilatation of the capillaries and 
compression of the glands of Lieberkuhn, are seen micro- 
scopically. The glands gradually atrophy, and in the late 
stages the mucous membrane presents a wasted appearance. 

Symptoms. — Frequent, foul, loose bcwel movements, to- 
gether with progressive emaciation, anaemia, later oedema of 
the extremities, or general anasarca and death, are the result 
of severe intestinal catarrh, with atrophic changes. In tuber- 
culous ulceration haemorrhages are likely to occur, and the 
stools contain tubercle bacilli and round cells. 

In milder cases the symptoms are not so persistent, and 
will depend upon the location of the process. The distinc- 
tion is not so marked here as in acute diarrhoeas, but we can 
often decide whether the small or large intestine is most 
prominently affected ; especially is this the case in the so- 
called chronic dysentery (see Amoebic Dysentery). 

In older children there is, beside the diarrhoea, distention 
of the abdomen, coated tongue, offensive breath, dark rings 
under the eyes, gritting of the teeth at night, and many other 
symptoms suggestive of "worms." Often constipation alter- 
nates with diarrhoea. As intestinal parasites will set up a 



DISEASES OF THE INTESTINES. 225 

catarrhal condition of the gut it is plain to be seen why simi- 
lar symptoms are present in both conditions. 

A chronic diarrhoea during infancy is frequently the fore- 
runner of rickets ; in older children it predisposes to tuber- 
culosis. 

In mucous diseases the entire alimentary tract is involved. 
The tongue is anaemic, flabby, and glossy in appearance. It 
may be fissured or mapped.' The appetite is impaired and 
the breath is offensive. Naturally the child's nutrition is 
impaired from the mechanical interference with the process of 
digestion and assimilation caused by the mucous secretion 
and the child looks pale and emaciated. 

The mucous flux, as Eustace Smith calls it, usually occurs 
paroxysmally and may be preceded by premonitory symp- 
toms, such as chilliness and abdominal discomfort. There 
may be a large number of mucous stools a day or only one ; 
indeed, constipation may alternate with the discharge of a 
large quantity of accumulated mucus. 

The child is neurasthenic ; often afflicted with night ter- 
rors or enuresis, and a variety of other nervous disturbances 
may be found associated. 

The course is prolonged and tedious. Some cases improve 
temporarily and then relapse ; others persist during life to 
some extent. 

Diagnosis. — The diagnosis of a chronic diarrhoea becomes 
self evident, but the differentiation of tuberculosis of the 
intestines from simple catarrh is often impossible without a 
microscopical examination of the stool. The discovery of 
tuberculous disease in the lungs or elsewhere, together with 
the presence of enlarged mesenteric glands or chronic peri- 
tonitis and haemorrhages, is strong evidence of tuberculous 
ulceration of the gut. 

In simple catarrh we should determine whether it be 
primary or secondary to some constitutional or organic dis- 
ease, such as rickets, malaria, nephritis. Mucous disease is 
readily recognized by the character of the stools. 



226 DISEASES OE CHILDREN. 

Treatment. — The diet should consist largely of milk, which 
may be given pure or modified, according to the age of the 
child. Meat should be avoided. Plenty of fresh air or a 
trip to the country are of decided benefit. Irrigation of the 
bowels may be employed when the stools are very offensive. 

Children that are rapidly loosing weight and strength re- 
quire mild stimulation. 

In severe cases of mucous disease the diet must be most 
rigorously supervised. It is often advisable to give nothing 
but water for several days ; then cautiously adding beef juice ; 
poached eggs ; dry toast or zweibach ; rice ; skimmed milk ; 
egg-nog. 

Lavage and irrigation of the colon are most valuable ad- 
juvants in the treatment of mucous disease. 

Arg. nitr. — Stools worse at night, or immediately after 
eating ; craving for sweets. 

Ars. — Worse at midnight ; stools brownish, very offensive, 
excoriating ; senile appearance. 

Calc. c. — Stools light or sour ; scrofulous diathesis ; pot- 
belly ; sweating about head ; mesenteric glands enlarged. 

Calc. phos. — Abdomen flabby ; stools greenish ; dark-com- 
plexioned, puny, undeveloped children. 

China. — Diarrhoea, with much flatulence ; anaemia, pros- 
tration. 

Graph. — Abundant whitish mucus in stools. 

Hepar. — Scrofulous subjects ; skin eruptions, acid dyspep- 
sia, craving for sour things ; fat-diarrhoea. 

Ipecac. — Clean tongue, nausea, constant pain in umbilical 
region, malarial type. — (W. L. Dodge.) 

Lach. — Stools very offensive; croupous enteritis ; great 
sensitiveness in ileo-caecal region. 

Kreosotum. — Stools grayish, very offensive ; child belches a 
great deal when carried about ; old-looking children. 

Merc. — Stool contains mucus in abundance, is excoriating, 
greenish, and voided with much straining. 

Phos. — Painless watery diarrhoea. The anus is relaxed and 
open. 



DISEASES OF THE INTESTINES. 227 

Phos. ac. — Painless yellowish diarrhoea, with great rum- 
bling in the intestines. 

Sulphur. — Worse early in the morning ; variable in color, 
excoriating ; prolapsus ani ; child is greedy ; mouth and lips 
dry and very red ; old expression ; the skin is dry or eczema- 
tous in various localities ; aversion to being washed. 

Mucous Disease. — The chief remedies in this affection are 
the Mercuries ; Kali bichromicum ; Colchicum ; Calcarea 
phosphorica ; Lycopodium and Argentum nitricum. 

Merc. viv. — This remedy I always prefer in any case of 
diarrhoea with an excessive amount of mucus. Should it 
seem insufficiently active the Bichloride, 3rd decimal tritura- 
tion, cautiously administered, should be tried. 

Kali bichrom. — Best suited to cases with pronounced gastric 
involvement. Dry, red, smooth and cracked tongue ; nausea 
and vomiting ; craving for acids ; gelatinous stools. 

Colchicum. — In the early stages. Stools consist of jelly 
like mucus ; sensation of coldness in stomach ; tympanites. 
Griping before stool. 

Calc. phos. — Many cases will require Calc. phos. as a con- 
stitutional remedy. The same may be said of Lycopodium, 
which is indicated more on its general symptoms than on the 
character of the stool. 

Arg. nitr. 3X trit. — Stools consist of green mucus mixed 
with undigested food particles {Calc. phos.) and are usually ex- 
pelled with considerable gas. The face is pale, sunken, and 
old looking. Mouth dry ; tongue cracked, with viscid mucus ; 
aphthous sores in mouth. Nervous symptoms are prominent 
(Lye). Craving for sweets. 

INTESTINAL TUBERCULOSIS. 

Primary intestinal tuberculosis is by no means as common 
a condition as was at one time supposed, and while quite a 
number of authentic cases are on record, still the develop- 
ment of tuberculosis primarily in the intestinal tract is rather 
the exception than the rule. Secondarily, tuberculous ulcera- 



228 DISEASES OF CHILDREN. 

tiou of the intestines is encountered in from one-third to one- 
half of all tuberculous cases coming to autopsy, being less 
frequent in infants than in older children, no doubt owing to 
the fact that infants succumb to the disease before the intes- 
tines have had an opportunity of becoming infected ; also be- 
cause of the different course assumed by tuberculosis in in- 
fancy, there being rarely a breaking down of pulmonary 
tissue with the formation of bacilli-laden sputum. 

Again, the belief that feeding infants upon milk from 
tuberculous cows is responsible for the majority of cases of 
infantile tuberculosis has been largely abandoned. It is con- 
ceded that bovine tuberculosis may, under circumstances 
most favorable to its transmission, be implanted upon the 
human organism and set up a primary intestinal tuberculosis, 
but this rarely takes place. Koch, in his famous address be- 
fore the British Tuberculosis Congress (July, 1901) attempted 
to prove that bovine tuberculosis was distinct from human 
tuberculosis and was never transmitted, but in this he is not 
unanimously supported. The requirements for infection by 
milk seem to be that the milk come from a cow suffering with 
tuberculosis of the udder, that the milk contain a great num- 
ber of bacilli and be ingested in large quantities and practi- 
cally constituting the sole diet of the subject in question. 
This being the case with infants and young children they are 
the ones mainly exposed to danger (Nocard). 

Pathology. — The favorite seat of the lesions is the small 
intestine, near the ileo-caecal region. Sometimes ulcers are 
found in the caecum, but rarely in the colon. Associated 
with ulceration there is almost invariably infiltration of. the 
mesenteric lymphatic glands, and when the condition has ex- 
isted for some time they become caseous. In some instances 
the affection of the lymph nodes plays the most prominent 
role. They become prominently enlarged, making it possible 
to feel them through the abdominal wall, and on account of 
the interference with the process of assimilation emaciation 
becomes most pronounced. This represents the so-called 
tabes mesenterica. 



DISEASES OF THE INTESTINES. 229 

In the early stages of intestinal tuberculosis small, yellow- 
ish nodules representing infiltration of the solitary follicles 
and Peyer's patches are encountered. They break down, 
leaving an ulcerating surface, with irregular border and over- 
hanging edges. The characteristic features of the tubercu- 
lous ulcer are its outline and border, and the direction of its 
long axis, which is at right angles to that of the gut. This is 
directly opposite to the direction assumed by typhoid ulcers, 
which run in the same direction as the gut. At times a 
tuberculous ulcer is encountered, almost completely encircling 
the gut. As the process is a slow one, the surface of the 
ulcer is covered with granulations, and perforation rarely oc- 
curs, owing to localized plastic inflammation of the serosa 
accompanying the process. 

Symptomatology. — Chronic diarrhoea with the occasional 
appearance of blood in the stools, or at times a severe haemor- 
rhage, are the characteristic symptoms of tuberculous ulcera- 
tion of the intestine, especially when these symptoms appear 
in a tuberculous subject. Diarrhoea is, however, not always 
present, and haemorrhage may be absent to the last. Again, 
diarrhoea is frequently associated with tuberculosis without 
any evidence of ulceration being present. Cases presenting 
the greatest difficulty in diagnosis are those of primary origin. 

The data upon which a diagnosis is to be based are the fol- 
lowing : Persistent diarrhoea, with occasional bloody stools 
or a haemorrhage in a child presenting evidence of tubercu- 
lous lesions elsewhere ; enlargement of the mesenteric lymph 
nodes ; tenderness* in the ileo-caecal region ; emaciation ; the 
presence of tubercle bacilli in the stool ; gradual onset of the 
symptoms. 

The prognosis is unfavorable. Diarrhoea is always an un- 
favorable event in a case of tuberculosis, as it interferes with 
the proper feeding of the patient — his most important weapon 
against the inroads of the disease. Primary cases, or such in 
which the disease has not made prominent headway else- 
where, offer the best prognosis. 



230 DISEASES OF CHILDREN. 

Treatment. — In the presence of diarrhoea the food must be 
carefully selected, avoiding meat and indigestible solid food. 
Sonps, milk, raw eggs, crackers and dry toast are the main 
articles of diet that are suitable. In case of a haemorrhage, 
food is best withheld for a time and an ice-bag placed on the 
abdomen. Supra-renal extract may be administered, one to 
two grains hourly, for several hours. 

The following remedies should be studied : 

Arsenicum jod., 3X trit. — A series of cases of abdominal 
tuberculosis in which diarrhoea was a prominent symptom 
has been reported by Day {Monthly Hoin. Review, No. 10, 
1897). He claims to have obtained excellent results from 
Ars.jod. in these cases. Personally, I prefer Iodofo?'?n, un- 
less there be pronounced indications for Arsenic. 

Calc. carb. — Pot-bellied, emaciated children ; tabes mesen- 
terica ; scrofulous diathesis ; pale or grayish, offensive stools. 

Calc. phos. — In Calc. phos. diarrhoea is the most prominent 
symptom, while in Calc. carb. the affection of the mesenteric 
glands plays the most prominent role. The child is ema- 
ciated ; abdomen soft and flabby ; stools frequent, undigested 
and mixed with greenish mucus. 

Iodoform 3X trit. has given most excellent results in chronic 
diarrhoea with emaciation, distention of the abdomen and en- 
largement of the mesenteric glands. It is not unusual to 
find evidence of tuberculosis elsewhere, such as infiltration of 
the lungs and tuberculous adenitis. As a rule, the appetite 
soon improves under its administration and the character of 
the bowel movements changes decidedly for the better. 

Kreosotnm. — Offensive, grayish stools ; old looking, ema- 
ciated children. Kreosote is a valuable remedy in the diar- 
rhoea of syphilitic infants. 

Nitric acid. — Ulceration of the bowel, with bloody stools; 
cracking of the corner of the mouth ; ulceration of the mouth 
and tongue ; strong smelling urine. 

Phosphoric acid is a valuable remedy in the debilitating 
diarrhoeas secondary to pulmonary tuberculosis. 



DISEASES OF THE IXTESTTXES. 231 



CONSTIPATION. 



Constipation is common during infancy, and is especially 
likely to result from the use of an unsuitable food and the 
neglect of certain hygienic measures. In regard to the former, 
insufficient fat and excess of proteids or starchy food, or the 
exclusive use of boiled milk, is a common error, and irregu- 
larity in feeding ; insufficient exercise, bathing and fresh air 
are additional causes. Constipation in infants sometimes re- 
sults from insufficient food or a milk formula that is too 
weak. Owing to the great length of the intestinal tract and 
the exaggerated curve of the sigmoid flexure (Jakobi), to- 
gether with the feeble muscular coats of the gut, faecal resi- 
due in either insufficient or excessive amounts is usually ex- 
pelled with difficulty or retained until its moisture is absorbed. 
Congenital dilatation and hypertrophy of the colon (Henoch) 
has also been found, together with obstinate and fatal consti- 
pation. 

Physiological disturbances inducing constipation are insuf- 
ficiency of biliary and intestinal secretion. 

Later in life we encounter constipation depending upon 
errors in diet, irregularity in attending to the calls of nature, 
insufficient fresh air and sunshine, and intestinal indigestion, 
but we must be wide awake to the fact that frequently it is 
but a symptom of some constitutional ailment of far greater 
importance, namely, rickets, tuberculous meningitis, anaemia 
and various organic disturbances. 

Painful local affections often lead to constipation through a 
dread of evacuating the bowels. In such cases I have seen 
impaction of faeces with obstruction of the bowels result, 
making it necessary in one case to incise the sphincter in 
order to remove the hard scybali. 

Symptoms. — As constipation is but a symptom in itself we 
must search for the cause, remedy that, if possible, and apply 
the necessary measures toward the relief of the intestinal tor- 
por. Although the stool is usually hard, dry, lighter in color 



232 DISEASES OF CHILDREN. 

than normal, and passed in small pieces, still this is not invar- 
iably the case, for frequently the stool is soft, papescent, and 
of the proper quantity and color, the rectum seemingly being 
unable to expel it. I recall the case of a child five years old 
complaining of intense pains in the sacral region simulating 
sacro-iliac disease. The bowels moved daily, but scantily and 
with pain. An examination of the rectum under an anaes- 
thetic revealed a complete impaction of the rectum and sig- 
moid flexure with hardened faeces, which was with difficulty 
removed. 

At times we are able to feel masses of impacted fsecal mat- 
ter in the colon by abdominal palpation. This may be mis- 
taken for a tumor, but its characteristic putty-like consistency 
and its tendency to move along the intestinal tract are suffi- 
cient data to eliminate errors of this kind. A routine exam- 
ination of the abdomen for fsecal concretions should be made 
in all cases where such a condition is likely to occur. The 
physician who follows this rule will be surprised to find how 
often, especially in acute diseases, an impacted colon and sig- 
moid flexure will be encountered. I would also advise a more 
frequent resort to digital rectal examinations. 

Treatment. — Infants fed on artificial food should have the 
percentage of fat, and sometimes the sugar, increased or a 
predigested carbo-hydrate added to the milk, such as Iyiebig's 
Food or Mellin's Food. Breast-fed infants often receive much 
benefit from an occasional teaspoonful of olive oil. A 
drink of sugar-water once or twice daily will often act bene- 
ficially. 

In the case of older children the same measures hold good, 
but as their diet is more varied and more easily regulated, 
dietetic treatment is more satisfactory here. A little honey 
at breakfast, together with oatmeal, graham wafers and fruit, 
and at the subsequent meals the addition of stewed fruits, 
green vegetables and the avoidance of meat and starchy foods 
in excess, yield most satisfactory results. At the same time 
the child must be encouraged in the free use of water be- 



DISEASES OF THE INTESTINES. 233 

tween meals and regular habits at stool. A teaspoonful of 
olive oil after meals is very beneficial. 

Enemata are of decided value in habitual constipation, and 
are necessary to soften the stool where anal fissures exist. If 
the enema be not given in excessive quantities, and nothing 
more irritating than soap and water or normal saline be used, 
there is no danger of creating an enema habit. 

Massage is also a most valuable adjuvant to the therapeutics 
of constipation, and is more applicable to infants than to 
older children. (See chapter on "Nursing.") 

The most useful and most frequently indicated remedies for 
the uncomplicated cases are Alumina, Bryonia, Nux vom. and 
Sulphur. 

Alumina. — The stool is soft and papescent ; child makes no 
effort to move its bowels, and if so, they are usually unsuccess- 
ful : stool sticks to the anus like putty. 

Bryonia. — Stools large and dry, as if burnt. "Constipation 
after castor oil." 

Graphites. — Stool consists of small balls bound together by 
mucus ; fissura ani ; eczema ani ; fat babies with skin erup- 
tions. 

Lycopodium. — Flatulent distension of abdomen; red sedi- 
ment in urine; child cries when attempting to pass the stool 
owing to painful contraction of the sphincter. 

Mercurius dulcis 2x trit, a tablet three times a day for in- 
fants, or two tablets four times daily in older children, is indi- 
cated when the biliary and intestinal secretion is deficient. 
This remedy should not be given over a prolonged period of 
time. 

Ox-gall is a harmless substance possessed of decided chola- 
gogue properties and is a valuable remedy in many cases of 
constipation. It may be given in one-grain chocolate-coated 
tablets. 

Nux vomica. — The child strains and grunts, but passes little 
or no stool ; the abdomen is distended, hernias are apt to pro- 
trude from the constant straining and kicking. 
16 



234 DISEASES OF CHILDREN. 

Plumbum. — "This remedy is suited to infantile constipa- 
tion where the moisture of the stool has been absorbed and it 
is hard and lumpy, causing fissures, and is voided with diffi- 
culty, requiring severe straining." — (Fischer.) 

Sulphur. — Constant urging with prolapsus ani or haemor- 
rhoids, which bleed profusely at times. Habitual constipa- 
tion ; infantile atrophy and malnutrition ; anus very sore after 
stool ; intestinal indigestion, lips red, tongue dry and papillae 
prominent through a dirty coating ; hunger between meals ; 
urine offensive with greasy pellicle ; dry, unhealthy skin. 

Beside these remedies, one of the following may suggest it- 
self from its prominent objective local and general symptoms. 

Ammonium mur. — Hard, crumbling stool, followed by a 
soft stool, covered with a glairy mucus. 

Calcarea carb. — Stools large, light; oozing of offensive 
fluid from anus. Rickets. 

Caust. — Much urging and straining at stool, with redness 
of face and anxiety ; passed best in the standing position. 

Chelid. — Stool like sheep's dung; liver sensitive. 

China. — Light stools ; difficult, even when soft {Alumina). 

Ferrum. — Anaemia ; flushing of face. 

Hydrastis. — "After purgative medicines." — (Goodno.) 

Kali carb. — Stool too large to be expelled ; proctalgia. 

Nat. mur. — Stools hard and dry, producing fissures of 
anus. 

Nitr. ac. — Stool hard and scanty ; fissures with splinter- 
like pains. 

Opium. — Obstinate constipation ; stool consists of small, 
hard, black balls. 

Phos. — Stool long and narrow. 

ACUTE INTESTINAL OBSTRUCTION. 

Obstruction of the bowels may result from a variety of 
causes, the most frequent being intussusception. The obstruc- 
tion occurring in appendicitis is in reality a paralysis of the 
bowels due to septic peritonitis. 



DISEASES OF THE INTESTINES. 235 

A twisting of the gut, known as volvulus, is occasionally 
met with in children, who at the same time present adhe- 
sions or bands of inflammatory tissues remaining after an 
attack of peritonitis, or in whom a congenital slit in the 
mesentery is found, such a case being cited by Henoch 
^Vorlesungen uber Kinder krankheiten" Berlin, 1897). They 
are, in fact, examples of internal strangulation. A case of 
acute obstruction from flexion due to a drawing back and twist- 
ing of the intestine by an adhernt Meckel's diverticulum is 
reported by Van Lennep {Hahnemannian Monthly, Oct., 1890). 
Laparotomy was performed on the sixth day of the ob- 
struction and the child recovered. Incarcerated and strangu- 
lated hernice are rare in childhood, but have been observed. 
Foreign bodies or masses of ascarides becoming firmly lodged 
in the bowel are also the cause of the obstruction at times. 

Intussusception and the other forms of obstruction are 
surgical diseases, but as the medical practitioner is the first to 
see them it is eminently important that he should be thoroughly 
acquainted with their clinical course and be able to promptly 
recognize them. The prognosis only too frequently depends 
upon an early diagnosis. If the true nature of a case of in- 
tussuception or fulminating appendicitis be overlooked until 
sloughing of the bowel in the one case and septic peritonitis 
in the other have set in every chance of recovery, even in the 
event of an operation, will have been lost. 

INTUSSUSCEPTION. 

Intussusception is most frequently seen in children during 
the first year, and has been found to occur oftener in boys 
than in girls. Although diarrhoea with constant straining 
has at times seemed to be the exciting cause, it has occurred 
just as well during torpid conditions of the bowel. 

Intussusception consists of the invagination of one portion 
of the intestine into another, most frequently the lower end 
of the ilium, together with the caecum, into the colon. The 
invaginated portion produces a sausage-shaped tumefaction in 



236 DISEASES OF CHILDREN. 

the region of the caecum or transverse colon, often advancing 
over into the left iliac region. It may at times be felt in the 
rectum, even protruding therefrom for a considerable length. 

Neither of these signs, however, may be discernible, par- 
ticularly the tumor, which cannot be felt after the abdomen 
becomes much distended. 

The onset is usually sudden, the symptoms being colicky 
pains, with vomiting and straining at stool. The lower 
bowel soon becomes emptied of its fsecal contents, after which 
passages of blood and mucus make their appearance. The 
vomiting becomes stercoraceous unless the obstruction is re- 
lieved, and the patient dies in collapse. 

Spontaneous reduction or sloughing of the invaginated 
portion of the gut, and successful union with restoration of 
the lumen of the canal may occur in exceptional instances. 
Such a case has been recently reported by Steinmeyer. 
(" Munch. Med. Wochenschrift" vol. xliii, 1896.) Stricture, 
however, follows nature's cure in the majority of instances. 

The prognosis is grave unless the intussusception can be 
reduced within a reasonable time of its occurrence. Gibson 
(N. Y. Medical Record, July 17, 1897) estimates the mortality 
as 53 per cent, from a collection of 249 cases. It is claimed 
by many that operation should not be undertaken after 
twenty-four to forty-eight hours. 

Diagnosis. — Symptoms of obstruction, together w T ith the 
presence of the sausage shaped tumor in the abdominal 
cavity and in the rectum, bloody stools and active movements 
of the intestinal coils above the seat of obstruction and pro- 
jectile vomiting are positive evidences of intussusception. 

APPENDICITIS. 

Appendicitis is seldom seen as early as intussusception, 
only exceptionally occurring during infancy, and rarely be- 
fore the fourth year. The causes are the same as in adults. 
Appendicular colic is more common in children, however, 
than in adults, owing to the more patulous state of the open- 



DISEASES OF THE INTESTINES. 237 

ing of the appendix into the caecum, permitting the entrance 
of faecal concretions (stercoraceous appendicitis). These cases 
usually recover, as the appendix is able to empty its contents 
back into the caecum more rapidly than in the adult. Every 
case of severe colic in a child under ten years, therefore, 
should be examined for tenderness over the base of the ap- 
pendix, which, if present, would indicate inflammatory re- 
action. 

It has been observed that appendicitis in children is more 
frequently of the fulminating variety than in adults. 

The catarrhal variety is characterized by its mild course 
and absence of complications. 

The perforative variety may, from the beginning, be ac- 
companied by localized plastic or suppurative peritonitis, or 
without any warning an apparently mild case may suddenly 
perforate and set up a general septic peritonitis. 

The clinical features of appendicitis are very characteristic, 
and cannot be more tersely or more clearly described than the 
following paragraph from Van Lennep's monograph (" Ap- 
pendicitis," Trans, of the American Institute of Horn., 1897) 
indicates : 

" There is the history of improper eating, or perhaps ex- 
posure to cold, associated with the menstrual period in the 
female; occasionally overexertion, particularly in the sed- 
entary, or possibly a direct traumatism. Then, what have 
been aptly termed the cardinal symptoms: (1) Pain, at first 
peri-umbilical or diffuse, but soon referred to the right iliac 
fossa, unless the appendix points elsewhere. (2) Tenderness, 
almost always present at the junction of the organ with the 
caecum (McBurney's point) ; sometimes associated with other 
sore spots corresponding with distal lesions or their products. 
(3) Muscular rigidity, to corroborate tenderness, which may 
vary from a local or general board-like stiffness to an indis- 
tinct, circumscribed muscular tension, or a barely appreciable 
difference between the two recti at their costal margin. Be- 
sides this three-legged stool, as Hering would have termed 



238 DISEASES OF CHILDREN. 

these cardinal symptoms, are the well-known initial con- 
comitants : Sudden onset, the coated, flabby and indented 
tongue ; the vomiting, which, when present, is from an over- 
loaded or rebellious stomach ; constipation, sometimes pie- 
ceded by an irritative diarrhoea ; distention, usually local in 
the early ' tympanitic tumor,' due to atony of the caecum from 
an irrritated appendix ; and, lastly, as might be expected, a 
moderate temperature rise and pulse acceleration." 

Diagnosis. — With the presence of the above symptoms the 
diagnosis of appendicitis is not difficult. From intussuscep- 
tion it is differentiated by the absence of projectile or 
stercoraceous vomiting, bloody stools and intestinal tumor. 
Furthermore, in intussusception there are active movements 
of the intestines, while in appendicitis " actively-moving in- 
testinal coils are not seen or felt, and gurgling is scanty or 
absent " (Van Lennep). Referred pain in the right iliac 
fossa is not uncommon in pneumonia of the right base in 
childhood. It is caused by irritation of the trunks of the last 
dorsal spinal nerves at the site of their exit from the spinal 
foramina. When there have been recurring attacks of ap- 
pendicitis we can often palpate the thickened appendix 
through the abdominal wall. 

Treatment. — Although every case of intussusception and 
appendicitis is by no means a surgical one, and careful pre- 
scribing together with the proper management of the case 
yield the best results in non-perforative appendicitis and in 
reducible cases of intussusception, still the physician must be 
constantly on the alert and learn to recognize the indications 
calling for operation. 

In appendicitis, Van Lennep says: "My working-plan re- 
garding operation is about as follows: In a severe attack, 
characterized by sudden onset, and particularly by interne 
cardinal symptoms, with or without corresponding concomi- 
tants, operation should be undertaken at once. In a milder 
seizure, the more common form, recovery may be looked for, 
with the hope of an interval operation. In deciding the ques- 



DISEASES OF THE INTESTINES. 239 

tion of persistence in such cases I have come to rely more 
than ever on the twenty-four hour limit, and I believe that 
whenever doubt or would-be conservatism has induced me to 
delay, I have had cause to regret the inaction. Benign cases 
will show signs of improvement within twenty-four hours, 
while unfavorable cases, requiring operation, usually grow 
worse during this time, and become dangerous from the pos- 
sibility of perforation with septic infection of the peritoneal 
cavity." 

In the case of intussusception, reduction should be attempted 
as soon as possible by means of taxis carefully applied and 
inflation of the bowels with fluids or air. This is unsafe after 
the third day, by which time firm adhesions will have formed- 
The child is best anaesthetized, a soft-rubber catheter intro- 
duced into the rectum, and by means of a fountain syringe, 
held at a height of three feet above the child's buttocks, from 
a pint to a quart of warm normal saline solution may be 
allowed to run in gradually, while the patient is inverted and 
the abdomen manipulated to aid in the reduction. Henoch 
recommends the use of ice-water. The operation is not with- 
out danger, rupture of the bowel having occurred where the 
height of the fluid was four and one-half feet (Harrington, 
Boston Med. and Surg. Jour.)\ here, however, the injection 
was used after the third day. 

Failing in this, laparotomy is the last resort, and the earlier 
performed, the greater the chances for recovery. 

For the relief of the troublesome vomiting, lavage of the 
stomach is highly recommended by many writers. 

Early in the attack such remedies as Bell, Nux vom., 
Colocynthis, Cupr. and Gelsem. may be of decided benefit. 
On the whole, Bryonia seems best indicated to check the 
plastic inflammation. 

In appendicitis an opening of the bowels must be obtained 
as scon as possible by the judicious use of enemata, to be fol- 
lowed by a saline purge when improvement begins. A liquid 
diet is also imperative. For relief of pain and control of the 



240 DISEASES OF CHILDREN. 

inflammation there is nothing so efficient as the ice-bag. 
Heat is contra-indicated, acting as a poultice and favoring 
necrotic changes in the appendix. 

Nux vomica. — This is the most important remedy in the 
early stage, indicated by coated tongue, nausea and vomiting, 
colicky pains in abdomen, constipation with urging to stool, 
abdomen tender and bloated. 

Belladonna. — Intense pain and sensitiveness in the right 
ileo-csecal region, cannot bear the weight of the bedclothes or 
to be touched. There is high fever, flushed face, vomiting, 
patient lying motionless on back with right leg drawn up. 

Bryonia. — Inflammatory stage. Bryonia covers the patho- 
logical condition more closely than any other remedy, and its 
cardinal symptom, pain aggravated by motion together with 
inflammatory fever, thirst and constipation, are almost invari- 
ably present. 

Dioscorea. — Severe pain in abdomen, beginning in region 
of umbilicus and extending to right iliac fossa, which be- 
comes sensitive to pressure. The pain is constant, twisting 
in character, and becomes worse in paroxysms ; constipation 
and thirst. 

Mercurius sol. — Painful tumefaction in right ileo-csecal re- 
gion ; tongue broad and flabby, showing imprints of teeth ; 
constipation; fever, worse during night, with sweat, which 
gives no relief. 

Rhus tox. — Hard, painful swelling in right side of abdo- 
men ; patient lies on back with legs drawn up ; great restless- 
ness, but cannot lie on either side ; tongue dry and red, with 
triangular tip ; typhoid state. 

Sulphur is a most useful remedy during the intervals to 
prevent recurrence and remove the products of inflammation 
at the end of an attack. 

When suppuration is suspected Hepar will be indicated. 
Other remedies which have proven useful are Arsenicum, 
Carbo veg., Lycop., Plumbum, Veratr. alb. When these rem- 
edies are indicated septic peritonitis, as a rule, is present, 
making the prognosis most grave. 



DISEASES OF THE INTESTINES. 241 



INTESTINAL PARASITES. 



The parasites infesting the intestinal tract of children, 
which are of practical importance from the clinical stand- 
point in this country, are two round worms, the oxyuris ver- 
micidaris and ascaris lumbricoides, and two tape- worms, tcsnia 
saginata and tcenia solium. 

Regarding the disturbances produced by the presence of 
these parasites nothing definite can be said, as it cannot be 
determined positively that a child has worms until they are 
discovered in the stools, or a microscopical examination of the 
faeces reveals the eggs of whichever species may be present. 
Fortunately they are rare, and the symptoms attributed to 
worms are in many cases dependent upon some other disturb- 
ance of the general health, commonly chronic intestinal 
catarrh or rickets, and at other times even more serious or- 
ganic disease, which is often overlooked from the convenience 
of classing all children's complaints under the heading of 
"teething" and "worms." 

One who comes in contact with a large number of children 
soon learns to recognize the lack of dependence one can place 
in symptoms popularly considered diagnostic of worms. Time 
and time again an anthelmintic brings forth no worm where 
these symptoms exist, and, on the other hand, children in ap- 
parently good health, without a single suspicious symptom, 
will pass worms in great numbers. 

In the case of the oxyuris vermicularis, pruritus ani at 
bedtime, recurring regularly each night, in some cases even 
violent pains in the rectum ; enuresis, and in male children 
erections with consequent masturbation, are frequent symp- 
toms. These worms also migrate into the vagina in females? 
inducing leucorrhcea and masturbation. They are found in 
the faeces, and can be detected at night emerging from the 
anus. 

The ascaris lumbricoides is to be suspected when there are 
attacks of colicky pains ; intestinal catarrh with loose stools 



242 DISEASES OF CHILDREN. 

or mucus in the faeces; nausea and vomiting not due to dis- 
ordered stomach ; irregular appetite ; pale countenance with 
dark circles under the eyes; dilated pupils; itching of the 
nose ; gritting of the teeth ; restless sleep with starting, and 
atypical febrile disturbances. All of these symptoms may, 
however, be traceable to other conditions; and here, again, 
the worm or its eggs must be discovered and other diseases 
excluded before a positive opinion can be given. We meet 
with children who have repeatedly passed ascarides and yet 
present none of the above symptoms, while others have many 
of the symptoms but no worms. It is claimed that an extract 
of ascarides injected into rabbits proves fatal, and, therefore, 
that the parasites secrete toxic substances, to which are due 
the nervous symptoms of helminthiasis (Dematteis). 

Dr. La Fuente {Presse Medical) considers attacks of intes- 
tinal colic coming on suddenly, seizing the child usually at 
play, and confined to one part of the abdomen, and bilateral 
narrowing of the field of vision as pathognomonic signs of as- 
carides. During the attacks of colic the abdomen is quite 
sensitive to palpation at the seat of the pain. This symptom 
I have been able to verify. We must, however, be on our 
guard and not mistake an attack of appendicitis for this con- 
dition. The narrowing of the field of vision is at times so 
pronounced, according to the above observer, as to be readily 
detected by passing the finger to and fro before the child's 
eyes. While these symptoms should be considered as pre- 
senting strong evidence of helminthiasis, still we cannot give 
a positive opinion until every effort has been made to discover 
the worms or their eggs in the stools, as other conditions ma}' 
produce similar disturbances. 

Tape-worms are the least common variety in children, but 
cases are occasionally seen. They are usually unsuspected 
until segments of the worm are passed, although tape-worms 
may produce marked anaemia in the young. In every case of 
pronounced anaemia the stools should be examined for para- 
sites. 



DISEASES OF THE INTESTINES. 



243 



Morphology. — The oxyuris vermicularis, also known as 
the thread-worm and seat-worm, is a small, whitish, thread- 
like worm, attaining a length of 10 m.m. in the case of the 
female, the male being 4 m.m. The female has an acuminate 
tail, while the male is blunt (Fig. 31). They infest the lower 
ileum and upper colon, often in great numbers. The females 
prefer the caecum and the colon, according to Zenker and 
Heller (Ziegler, " Text-Book of Pathological Anatomy"\ and, 
when mature and egg-bearing, migrate into the colon and 
rectum to deposit their eggs, whence they also creep out of the 
anus at night. The eggs are oval, 
flat on one side and rounded on the 
other, and exceedingly small. Before 
they can develop they must first 
enter the stomach of some host, 
and it is quite likely that a child 
often reinfects itself by swallowing 
the eggs from its own colony of 
parasites. 

Ascaris lumbricoides — This is the 
common round worm, being cylin- 
drical in shape, with tapering ex- 
tremities and light reddish-brown in 
color. The female may attain a 
length of fifteen inches ; the male 
eight to ten inches. The eggs are 
larger than those of the oxyuris, 
and possess a double shell, the 
contents being dark and granular. 
1-340 inch in length (Fig. 32). The mature female sheds 
enormous numbers of these ova — according to Eschricht 
and Leuckart, 160,000 daily. The life-history of the ascarides 
is not fully understood. They infest mainly the small intes- 
tines, although they may be found at any point in the alimen- 
tary tract, sometimes even being vomited, and in rare instances 
inducing death by creeping into the ductus communis chole- 
dochus or into the larynx. 




FIG. 31. — OXYURIS VERMICU- 
LARIS. (V. JAKSCH. ) a, HE AD J 

b, males; c, females; d, 
EGGS. (SIMON, Clin- 
ical Diagnosis.) 

They measure about 



244 



DISEASES OF CHILDREN. 



Tcenia saginata. — This form of tape- worm is derived from 
beef, and is perhaps the most commonly met with variety in 
this country. It has a square head, with four suckers, but 
no hooks (Fig. 33). It may attain a great length, and the 
segments are very numerous, and longer than broad. The 
life-history of the worm is as follows : After the eggs are dis- 
charged into the intestinal tract by the mature segments, they 
reach the alimentary tract of oxen grazing on pastures where 
these infected stools have been passed. Here the embryos are 

liberated and find their way in- 
to the muscular tissue through- 
out the body, and sometimes 
into various organs, where they 
become converted into the cys- 
ticercus, or larval form. If this 
cysticercus is eaten with raw or 
insufficiently-cooked meat, the 
capsule is destroyed by the di- 
gestive juices and the contained 
scolex liberated, which attaches 
itself to the mucous membrane 
of the small intestine, where it 
soon develops into the fully- 
matured form by segmentation. 
Tcenia solium, also known as 
the armed tape-worm,is derived 
from pork, and differs from 
t. saginata in being equipped 
with a set of hooks besides 
two pairs of suckers (Fig. 34). 
This parasite is also much smaller than the other variety and 
is less frequently encountered in the United States. 

Treatment. — In the case of oxyurides nothing appears to 
give more desirable results than the daily use of warm salt- 
water enemata. They must be given as high as possible, for 
these worms are not confined to the rectum alone, as has been 




FIG. 32. — ASCARIS EUMBRICOIDES 

(V. JAKSCH.) a, WORM, HAEF 

NATURAL SIZE; b, HEAD, 

magnified; c, eggs. 

(SIMON. ) 



DISEASES OF THE INTESTINES. 



245 



pointed out. Owing to the possibility of reinfection, scrupu- 
lous cleanliness of the child must be observed. Lard may 
be applied to the anus at night to relieve the itching, or, what 






FIG. 33.— TAENIA SAGINATA. THE SEGMENTS ARE NATURAL SIZE; 
HEAD AND EGG MAGNIFIED. (9IMON.) 



acts better, Carbolated vaselin. For internal administration 
Teucriam is recommended, although Cina or Sulphur may 
be called for in some cases. " The nightly restlessness and 



246 DISEASES OF CHILDREN. 

intolerable itching which they produce as long as they exist 
are almost always relieved by Aeon" — (C. G. R.) Naphthaline 
may be used in suppositories (see below). 

Ascarides are usually promptly expelled by the administra- 
tion of Santonin. This is best given in the first decimal 
trituration, a two- to five-grain powder, according to the age 
of the child, three times daily, followed, on the morning of 
the third day, by a laxative, if necessary. 

Naphthaline is recommended as an anthelmintic, its most 
decided power being over the oxyuris, although it is also 
capable of removing round worms. One to five grains, ac- 
cording to the age, is administered on an empty stomach, fol- 
lowed by a cathartic, such as castor oil. In the case of seat 




FIG. 34. — HEAD OF TAENIA SOLIUM, AFTER LEUKHART. ('.SIMON.) 

worms a rectal suppository of Naphthaline (two to five grains) 
may be tried after a salt enema. This is preferable to its 
internal administration. 

One of the following remedies will be useful to remove the 
intestinal catarrh which often remains for some time after the 
worms have been expelled. 

Cina. — Sickly, anaemic children, with pale face, dark 
rings under the eyes ; irritable, cross disposition ; great nerv- 
ous irritability, waking from sleep in terror ; variable appe- 
tite ; picking at the nose ; constipation and itching at anus ; 
feverish during night ; milky urine. 

Spigelia. — Colicky pains in region of navel, usually worse 
evenings and accompanied by palpitation of the heart, twitch- 



DISEASES OF THE INTESTINES. 247 

ing of the facial muscles or strabismus ; anaemia, with green- 
ish hue of the skin ; intestinal catarrh. 

Stannum. — Chronic indigestion, moaning during sleep, 
sluggish disposition ; "it prefers to lie on its stomach, to re- 
lieve the abdominal suffering " (Fischer). Stannum is said 
to kill the ascarides when used in the lower triturations, after 
which they can be expelled by a purgative. 

Sulphur. — Pale, sickly look ; eyes sunken, with blue mar- 
gins ; canine hunger ; empty, faint feeling before dinner ; 
alternation of constipation and diarrhoea ; itching about anus ; 
emaciated, dirty-looking children, who are filthy in their 
habits. 

For the expulsion of the tape-worm the oleoresin of felix 
mas is the most certain agent. A capsule containing fifteen 
minims is given on an empty stomach in the morning, and 
an hour later one to two teaspoonfuls of laxol may be ad- 
ministered. Should this not be successful, a larger dose must 
be used, preceded by a saline purgative, which has a tendency 
to remove all mucus from the intestinal tract, and thus fully 
expose the head of the worm to the action of the vermifuge. 



CHAPTER X. 

DISEASES OF THE PERITONEUM. 
ACUTE PERITONITIS. 

Acute peritonitis is rare during childhood ; it is most fre- 
quently seen in the new-born as a result of infection through 
the umbilical cord, or after the fourth year, when appendicitis 
begins to play a prominent role in the diseases of the abdo- 
men. The other cases of peritonitis may be classed as pri- 
mary and secondary, of which the latter is by far the more 
common. The primary variety develops suddenly from ex- 
posure to cold or traumatism, and in some instances a primary 
pjieumococcus peritonitis is found, as a rule, coexisting with 
meningitis, pleurisy, pericarditis or lobar pneumonia (poly- 
serositis of infants), although it is quite possible that the peri- 
toneal infection is secondary to the above conditions in most 
instances, especially in the case of pneumonia and pleurisy. 

Secondary peritonitis is more common and more easily ex- 
plained, as it results from the extension of an inflammation 
from other parts or through infection. Under the latter head- 
ing comes peritonitis attending perforative appendicitis, per- 
forating empyema, perforation of the intestine during typhoid 
fever, suppurating mesenteric glands, pyelo-nephritis, etc. 

Pathology. — Pathologically, three forms of peritonitis 
exist, namely, fibrinous, or plastic ; sero-fibrinous, and puru- 
lent. In the first stage there is injection of the peritonaeum, 
with loss of lustre of its surface, due to the deposit of a fibrin- 
ous exudate and infiltration of the membrane, together with 
destruction of the endothelium. This is followed by serous 
exudation, varying much in quantity in different cases. The 
fluid is turbid from the presence of leucocytes, and contains 
flakes of fibrin ; it may also contain red corpuscles. When 
the exudation is scanty, adhesion between opposing serous 



DISEASES OF THE PERITONAEUM. 249 

surfaces takes place ; when profuse, it accumulates in the per- 
itoneal cavity, seeking its most dependent portions, thus less- 
ening the liability to adhesions. In septic cases pus is formed 
from the beginning, while a sero-fibrinous inflammation may 
become purulent through an increased migration of leuco- 
cytes. Pneumococcus peritonitis is purulent throughout its 
entire course. 

Symptoms. — The onset of peritonitis is usually abrupt, 
and, as it is often a complication of other diseases, we must 
be prepared to recognize its early symptoms. Sudden devel- 
opment of sharp, cutting abdominal pains, rise of temperature 
to 104 F. or over, rapid, thready pulse, distended, hypersen- 
sitive abdomen, vomiting, and obstruction of the bowels or 
diarrhoea are the classical symptoms pointing to this affection. 

With the progress of the disease the abdomen becomes dis- 
tended and tympanitic, the abdominal walls rigid, and the 
patient lies on his back with the legs drawn up, to relieve the 
tension. Respiration is thoracic and is rapid and shallow, the 
pulse is rapid and thready, the features are pinched, the lips 
and extremities cyanotic, and pain is usually severe. Al- 
though diarrhoea may be present, there is most commonly a 
constipated condition of the bowels, and in septic cases ob- 
struction due to intestinal paralysis, indicated by vomiting ; 
uniform distention of the abdomen, with cessation of all 
gurgling sounds, is the usual condition. These cases rapidly 
go on to fatal collapse, although early operative interference 
will occasionaly save a life. In the very 7 young all forms of 
peritonitis are fatal ; in older children the non-purulent form 
is not so unfavorable. 

Treatment. — To relieve the pain, Bryonia and hot fomen- 
tations should be prescribed, and, although rest is a great es- 
sential in the treatment of peritonitis, it is better to keep the 
bowels open than to paralyze them by the use of Opium. 
Adhesions are less likely to occur, and fatal obstruction is not 
invited if we avoid such treatment. 

If the vomiting becomes troublesome all food must be with- 
17 



250 DISEASES OF CHILDREN. 

held, and nothing but cracked ice or a little hot tea allowed ; 
champagne is very useful in such cases. Lavage also stands 
highly recommended for this complication. 

The remedies most applicable to the early stages are Aeon., 
Bell.. Bry., and Ferrum phos. After these will follow Apis, 
Canth., Mercurius corr. and Rhus tox. when exudation sets 
in, Sulphur occupying a prominent position as an agent to 
absorb the exudate in the later stages. In grave cases, or in 
the advent of complications, we may find it necessary to em- 
ploy one of the following remedies : Arsenicum, Camph., 
Car bo veg., Lachesis, Lycop., Nux vom., Opium and Verat. alb. 

Aeon. — After exposure to cold ; hot, dry skin ; rapid, hard 
pulse, with high fever, great restlessness and anxiety. Cut- 
ting and darting pains in bowels or burning in the abdomen. 

Apis. — Exudation ; burning, stinging pains ; scanty urine ; 
loud, piercing shrieks and cerebral symptoms ; pneumococ- 
cus peritonitis coexisting with meningitis. 

Arnica. — After traumatism, in early stages. 

Arsenicum. — Later stages, impending collapse. Great 
anguish ; clammy perspiration ; the patient feels cold, and 
complains of burning pains in abdomen ; restless tossing, 
thirst, obstinate vomiting, distention of the abdomen and cold 
extremities. 

Camphor. — Collapse. 

Cantharis. — Intense inflammation, pinched features, rapid, 
feeble pulse, cutting and burning pains. — (Goodno.) 

Car bo veg. — Great distention of the abdomen, with par- 
alysis of the bowels. Extremities cold up the knees ; collapse. 

Lachesis. — Great hypersesthesia of the abdomen; compli- 
cating gangrenous inflammation of the appendix ; loquacious, 
adynamic fever. 

Merc. — When the exudate tends to become purulent, in- 
dicated by chilliness, followed by sweat ; starting in sleep ; 
cachetic expression ; foul breath ; emaciation ; obstinate 
vomiting. 

Nux vom. — Threatened paralysis of the bowels ; belching ; 



DISEASES OF THE PERITONAEUM. 251 

constant urging to stool without relief ; vesical irritation ; ob- 
stinate constipation and vomiting; chilliness from uncover- 
ing ; abdomen painfully distended. 

Opium. — Paralysis of bowels or antiperistaltic action; in- 
cessant vomiting, distention of abdomen, somnolence and 
stupefaction ; warm sweat. 

Rhus tox. — The Rhus tox. patient prefers to lie on his back 
with the legs drawn up, although the pains make him very 
restless. There is delirium at night, great prostration, and a 
brown tongue with red tip. 

Sulphur. — To hasten resorption of exudate. 

Veratr. alb. — Cold sweat on forehead, vomiting and purg- 
ing ; small rapid pulse ; great thirst, but drinking aggravates ; 
t anxiety, prostration and high fever. 

CHRONIC PERITONITIS ; TUBERCULOUS PERITONITIS. 

Chronic peritonitis is, in the majority of cases, of tubercu- 
lous nature, and when tuberculosis must be excluded the 
condition can be traced to a traumatism (Henoch), or to an 
inflammatory condition or neoplasm of the abdominal viscera, 
excepting in the case of foetal peritonitis, which is syphilitic 
(Silbermann). These infants are mostly born dead, although 
they may survive with permanent peritoneal damage. Tu- 
berculous peritonitis is usually secondary to intestinal tubercu- 
losis, infection taking place from caseating mesenteric glands ; 
primarily it may develop as the acute miliary type. It fre- 
quently develops after weaning, especially when milk from a 
tuberculous cow 7 has been fed to the child. 

Symptoms. — The disease presents itself under several dif- 
ferent types, more or less characteristic. 

The acute miliary tuberculous type presents the symptoms 
of acute peritonitis and is rapidly fatal, although remissions 
may occur. 

The ascitic type may be idiopathic or tuberculous. It is 
accompanied by an exudate of serum, or a purulent fluid in 
case of admixture of septic organisms. Idiopathic ascites 



252 DISEASES OF CHILDREN. 

has been observed in girls at the time of puberty ; the con- 
dition disappeared after the appearance of the menses 
(Quincke). 

In the adhesive type there is a matting together of the in- 
testines by dense bands of plastic exudate. Casseous masses 
are found in the mesentery and in the bands of fibrous tissue, 
and a firm mass is produced which is difficult to entangle 
after the abdomen has been opened. It eventually produces 
obstruction of the bowels. Felt through the abdomen, the 
mass gives one the impression of a neoplasm. The fibro- 
plastic variety presents adhesions together with fibrinous ex- 
udation, which may undergo caseous degeneration and induce 
ulceration into neighboring organs. Faecal fistulas forming 
in the neighborhood of the umbilicus are not uncommon in 
these cases. 

The course is slow and may terminate in spontaneous re- 
covery, especially in the fibro-plastic type, although death 
may result from extensive adhesions of the abdominal viscera. 
The ascitic iorm frequently recovers under proper treatment, 
but a general infection is always to be dreaded. 

Diagnosis. — The presence of fluid in the abdominal cavity, 
a well-defined nodular tumefaction due to adhesions and organ- 
ized exudate, or a sense of roughness imparted to the examin- 
ing hand when palpating and rubbing the surface of the 
peritonaeum against the viscera, are physical signs to be relied 
upon. The nature of the peritonitis must be decided by the 
age, diathesis, presence or absence of tuberculosis in other 
organs and the history of the case. The abdomen is uni- 
formly distended and fluctuating and shifting dulness in the 
flanks can be elicited in ascites without adhesions. Ridges 
and irregular contour of the abdomen suggest adhesions 
while stationary dulness speaks for sacculated fluid. In the 
adhesive variety an irregular, tumor can usually be palpated. 
Chronic obstruction of the bowels gradually develops when 
the adhesions constrict the gut. 

In the presence of marked ascites, hepatic disease must be 



DISEASES OF THE PERITONAEUM. 253 

excluded before a diagnosis of peritonitis can be made with 
certainty. In peritonitis the fluid contains more albumin 
and is of a higher specific gravity than in cirrhosis of the 
liver or other circulatory obstruction ; besides an abundance 
of cellular elements will be found in inflammatory serum. A 
predominance of mononuclear elements speaks in favor of 
tuberculosis. We may also be able to find the tubercle 
bacillus. 

Treatment. — Owing to the favorable results obtained by 
laparotomy, ever}' doubtful case should receive the benefit of 
an exploratory incision, which may materially help the pa- 
tient, if it will not result in a cure. The ascitic variety is 
the one especially benefited by laparotomy and evacuation of 
the fluid ; in the others it is of doubtful value. Sutherland 
(Archives of Pediatrics, Feb., 1903) is not in favor of surgical 
intervention as in forty-one cases observed by him the results 
of medical treatment of all varieties was much better (70 per 
cent, recovered) than of surgical treatment (50 per cent, recov- 
ered, 50 per cent. died). In connection with this the patient 
must be carefully fed, receiving highly-nutritious diet and cod- 
liver oil, besides remedies of known value in tuberculosis and 
acites. As constitutional remedies, Arsenicum jod., the Cal- 
careas, Sulphur, Silicea and Iodoform are to be selected from. 



CHAPTER XI. 

DISEASES OF THE RESPIRATORY TRACT. 

SPASM OF THE GLOTTIS. 

Spasm of the glottis, or laryngismus stridulus, is a neurosis 
which manifests itself as a contraction of the muscles narrow- 
ing the glottis, with resulting embarrassment of breathing. 
This affection has received many names, and has been con- 
fused with other affections from which it is entirely distinct ; 
thus, the asthma of Millar must, according to his description, 
be classed as spasmodic croup, and the thymic asthma of Kopp, 
if indeed such an affection can be established clinically, must 
also remain a distinct malady. 

The principal cause is rickets, craniotabes being especially 
associated with the development of these symptoms. 

Age and sex also play an important role in the etiology ; 
the greatest number has been observed in children under one 
year of age, but the first dentition period may be considered 
as including most cases. As regards sex, males furnish fully 
two times as many- cases as females. 

Peripheral reflex irritation or fright usually acts as an ex- 
citing cause. The attack begins suddenly, often during the 
night, but not necessarily so. The child starts with great 
embarrassment of breathing, attempting to inspire, which is 
only accomplished by interrupted efforts, and is accompanied 
by a wheezing or squeaking sound. For a moment the child 
presents the picture of one being suffocated, when suddenly 
the spasm gives way with a forcible, crowing, inspiratory ef- 
fort, and an attack of crying ensues. The prognosis is favor- 
able under ordinary circumstances, but when associated with 
severe cases of rickets it has frequently proven fatal. 

Congenital stridor of infants is a condition which may be 
mentioned in connection with glottic spasm. Its true nature 



DISEASES OF THE RESPIRATORY TRACT. 255 

is not fully understood. Robertson considers it a paralysis of 
the crico-arytenoideus posticus, while Thompson and Turner 
look upon it as imperfectly coordinated spasmodic action of 
the muscles of respiration, i. e., choreiform respiratory spasm. 
It occurs in young infants, and may exist from birth. The 
breathing is harsh and noisy. This noisy breathing may per- 
sist during sleep. The rhoncus is inspiratory and is loudest 
over the larynx. 

Constitutional treatment must be instituted between the 
attacks, paying especial attention to rickets when this is 
present. 

For the attacks there are several remedies highly recom- 
mended as specifics, but nevertheless it is necessary to differ- 
entiate individual cases. 

Sambuats. — This remedy was first recommended by Hahne- 
mann. According to Searle, "Burning, red, hot face, hot 
body, with cold hands and feet during sleep. On awaking 
the face breaks out into a profuse perspiration, which extends 
over the body and continues, more or less, during the waking 
hours; then, on going to sleep again, the dry heat returns 
(Xichol, "T/ie Larynx and Trachea in Childhood"). 

Another remedy of definite clinical value is Chlorine, ad- 
ministered in the first centesimal dilution, prepared freshly 
from a saturated solution of the gas in water. This remedy 
was introduced by Dunham, who made the following distinc- 
tion between it and Sambucus — under Chlorine there is diffi- 
culty in expiration, none in inspiration ; Sambucus has the 
reverse {Ibid). 

Belladonna. — This is the principal remedy when its well- 
known cerebral and circulatory symptoms are present. 

Gelsemium is highly recommended by Hale as a palliative. 

Beside these may be mentioned, as other leading remedies, 
Aconite, Arsenicum alb., Cuprum, Grindelia robusta. Ignatia, 
lodium, Sanguinarta. Of the last named Nichol writes: 
" My own experience leads me to look upon Sanguinarta as 
being the Imperial Guard of all the remedies for spasm of 
the glottis. ... I give it in the form of an acetous syrup." 



256 DISEASES OF CHILDREN. 



ACUTE CATARRHAL LARYNGITIS; SPASMODIC CROUP. 

This form of croup, which must be distinguished from true 
croup or. pseudo-membranous laryngitis, is a common affection 
of childhood, being a catarrhal inflammation of the lining 
membrane of the larynx associated with spasmodic action of 
the interior laryngeal muscles, thus giving the disease a par- 
oxysmal character. 

The anatomical and physiological peculiarities of the larynx 
and nervous system of young children, namely, the relative 
smallness of the larynx and rima glottidis, the great vascular- 
ity of its lining mucous membrane and the heightened reflex 
excitability of its nerve-supply, offer a ready explanation for 
the frequency of this malady during childhood and the 
peculiar type it assumes. 

Etiology. — The chief exciting causes are exposure to cold, 
draughts or wet weather ; acute indigestion and direct irrita- 
tion, such as the inhalation of irritating vapors, /Attacks oc- 
cur more frequently during the winter and early spring than 
in the milder and dryer season. Beside all this, however, 
there seems to be an individual predisposition to the disease, 
often hereditary, or simply a catarrhal tendency or nervous 
temperament. Male children are more frequently attacked 
than females, and the age at which it is most likely to occur 
is between the second and third year. 

Symptomatology. — The characteristic feature of spasmodic 
croup is its paroxysmal nature. The child may have been 
apparently well during the day, but towards night a ringing, 
metallic cough — sometimes before retiring, at other times not 
until the child has been put to bed — makes its appearance. 
There may be, instead, a slight hoarseness ; but notwithstand- 
ing this, the child usually falls asleep, and sleeps soundly, 
only to suddenly awaken at midnight, or shortly before, with 
all the characteristic symptoms. The breathing is much op- 
pressed, inspiration almost impossible, much prolonged, and 
accompanied by a harsh, rasping sound, while with expira- 



DISEASES OF THE RESPIRATORY TRACT. 257 

tion there is a ringing, metallic (croupy) congh. The child 
is much alarmed, exceedingly restless, and the face presents a 
picture of anxiety and distress. Cyanosis and recession of the 
supra-clavicular and supra-sternal spaces is marked, if the at- 
tack be long-continued and severe ; often the sufferer grasps 
at the throat in the effort to relieve the obstruction. 

The attack may last from a few minutes to an hour or 
longer, not, however, in one continued degree of severity. A 
second milder attack is likely to occur during the same night, 
and on the following two or three nights it may again be 
looked for with all probability. A moderate amount of fever, 
together with some catarrhal secretion, is usually present. 
The condition rarely results fatally. 

A more severe form of acute laryngitis often confronts us 
and makes it difficult to decide whether the case be one of 
catarrhal or croupous inflammation. In these cases there is 
fever; continuous hoarseness; more or less dyspnota and 
paroxysms of suffocative cough, together with abundant 
tenacious mucous secretion. So eminent an authority as Holt 
tells us that it is at times impossible to differentiate such a 
condition from true croup and that at the autopsy one is sur- 
prised at not finding membrane when such a laryngitis has 
proven fatal. 

Diagnosis. — Pseudo-membranous croup is the most im- 
portant condition, and often the most difficult one from which 
false croup is to be differentiated. In the absence of grave 
constitutional symptoms ; complete relief oi all symptoms be- 
tween attacks, which are always paroxysmal and most likely 
to occur shortly before midnight ; absence of exudation in 
the pharynx or upon the tonsil, and the presence of hoarse- 
ness rather than suppression of the voice, eliminate true croup 
with a fair amount of certainty. Again, auscultation of the 
larynx, revealing a dry, wheezing or hissing respiration and 
a hoarse-sounding, croupal cough, is, according to Trousseau, 
not a sign of exudation in the larynx, but rather one of its 
absence. In severe cases of acute catarrhal laryngitis the 



258 DISEASES OF CHILDREN. 

fever is higher than in diphtheritic croup and there is no 
exudation to be seen in the pharynx. A laryngoscopic 
examination reveals the epiglottis, the arytenoids and the 
vocal cords deeply congested and swollen and covered with 
mucous secretion instead of membrane. 

Laryngismus stridulus is to be differentiated from mild at- 
tacks, which can usually be done readily by a careful com- 
parison of the two ailments. 

Pseudo-Membranous Laryngitis, being almost invariably a 
laryngeal diphtheria, will, for the sake of convenience and 
clinical importance, be described under the subject of "Diph- 
theria." 

Treatment. — During an attack the child should be sup- 
plied with steam inhalations as soon as possible, which may 
be accomplished by simply holding a basin of hot water be- 
fore it, or, in case a croup-kettle or a steam spray are access- 
ible, a tent should be constructed over the child and the 
stream directed under the same. If this does not offer suffi- 
cient relief a cold pack should be applied to the throat. Care 
should be exercised not to allow the child to inhale the vapor 
too hot for fear of aggravating the symptoms. 

Remedies are both useful to mitigate the severity of the 
paroxysm and to overcome the tendency to recurrence. 

Aconite, Hepar and Spongia, as recommended \>y Bcenning- 
hausen, are of exceptional service when given successively, 
although it will be found usually that one begins in its path- 
ogenesy where the other leaves off, and it is therefore wisest 
to continue the single use of each of these remedies as long as 
it seems indicated. 

Aeon. — High fever, dry skin, great restlessness, nervous 
temperaments; after exposure to cold winds or draughts') 
checked perspiration. 

Acetic acid is a valuable remedy in croup, especially when 
there is an accumulation of mucus in the larynx. A few 
drops of the acid added to the water feeding the steam spray 
makes a useful adjuvant. The indications under which it 



DISEASES OF THE RESPIRATORY TRACT. 259 

does most good are the following: "Croup, especially when 
the face is bright red. (Diluted in water, ten drops in a tum- 
bler of water with some sugar, a teaspoonful every hour or 
two.)" {Hering^s Condensed Mat. Med.) 

Bell. — Barking cough; pre-paroxysmal symptoms of at- 
tacks; child wakes suddenly: great vascular excitement; 
rawness and pain in larynx, with hoarseness. 

Spongia. — "Its most remarkable therapeutic virtue is to 
cure croup. Among other symptoms, it is indicated in this 
disease by difficulty in breathing, as though a plug had lodged 
in the throat, and as though the larynx were so constricted 
that breath cannot pass through it." — (Hahnemann.) "The 
sawing respiration of this remedy is also characteristic. The 
aggravation is in the evening; Hepar in the morning." — 
(Hering.) 

Hepar. — Deep, rough, barking cough ; rattling of mucus in 
larynx and trachea ; laryngeal symptoms remaining after the 
paroxysm. 

Permanganate of Potash, in the experience of Dr. B. H. 
Sleght {Horn. Eye, Ear and Nose Journal, June, 1901), is a 
specific for the croup paroxysm given in teaspoonful doses of 
a cherry-red aqueous solution. 

Phosphorus. — This remedy is recommended highly by sev- 
eral observers, often acting curatively when the above rem- 
edies have failed to give decided relief. It is especially useful 
for the hoarseness and bronchitis remaining after the attack. 

Ipecac and Lobelia are extensively used by many physicians 
in this affection, and undoubtedly yield excellent results, pro- 
vided they happen to suit the case. 

ACUTE BRONCHITIS. 

Acute catarrhal bronchitis is one of the common ailments 
of childhood, seen especially in the rachitic or those in whom 
malnutrition and anaemia are a prominent feature. Children 
who are closely confined, either in the poorer crowded quar- 
ters or in nurseries insufficiently aired and sunned, are partial- 



260 DISEASES OF CHILDREN. 

larly susceptible to bronchitis, for which reason most cases 
prevail during the winter months and early spring. 

Secondarily, bronchitis accompanies measles, whooping- 
cough, influenza, typhoid fever and several others of the in- 
fectious fevers almost unfailingly; its pathology and symp- 
tomatology are the same in these cases as in the primary 
variety. 

Several varieties of acute bronchitis are to be recognized. 
The mildest form is simply an acute catarrhal condition, 
afebrile in its course and unaccompanied by constitutional 
disturbances. Baginsky prefers to call it bronchial catarrh in 
contradistinction to actual bronchitis. It is very prevalent 
among infants during the colder months of the year, and 
seems to be dependent upon atmospheric changes and consti- 
tutional predisposition. 

Acute febrile bronchitis is infectious in origin, is accom- 
panied by constitutional symptoms, and tends to spread to 
the finer ramifications of the bronchial tree, setting up suffo- 
cative symptoms — capillary bronchitis. When the process in- 
vades the pulmonary parenchyma, which takes place both by 
continuity of structure and by the formation of independent 
foci of solidification through the agency of micro-organism, 
we are confronted by a broncho-pneumonia. 

Pseudo-membranous bronchitis, or fibrinous bronchitis, is in 
the majority of cases due to the diphtheria bacillus and may 
follow this disease. I have seen it in conjunction with pneu- 
monia. The pus organisms may also induce fibrinous exuda- 
tion upon the bronchial mucosa. A chionic form of obscure 
origin is to be encountered. 

Pathology. — As in the case of spasmodic croup, a catarrhal 
inflammation of the bronchial tubes during infancy is of more 
serious import and accompanied by more suffocative symptoms 
than a similar condition in adult life. The greater vascularity 
and looseness of the mucous membrane, and the relatively 
smaller size of the air-vesicles and smaller amount of breath- 
ing-surface in the infantile respiratory tract, are the reasons 



DISEASES OF THE RESPIRATORY TRACT. 261 

for these attacks assuming so dangerous a course. Outside 
of its tendency to spread to and involve the finer ramifications 
of the bronchial tree, acute catarrhal bronchitis presents noth- 
ing apart from the same process in adults. In fatal cases the 
mucous membrane appears swollen, injected, ecchymosed, and 
covered with mucus and purulent secretion. In the larger 
tubes the lining membrane alone is affected, while the smaller 
and finest ones are involved throughout their entire thickness 
in the inflammatory process. The lungs are usually emphy- 
sematous, from dilatation of the air-vesicles and choking up 
of the capillary tubes with secretion. Areas of atelectasis are 
also encountered. 

Every grade, from simple hyperemia of the mucosa with 
desquamation of epithelial cells up to the highest type of 
inflammatory reaction with infiltration of the sub-mucous 
tissue ; necrosis of the epithelium and croupous exudation 
upon the surface of the membrane will present itself accord- 
ing to the severity and nature of the infection. The mucous 
membrane is covered with a tenacious secretion rich in pus 
corpuscles. Dilatation of the bronchi is a common result of 
severe bronchitis in children. 

Symptomatology. — Bronchitis may run a mild or a danger- 
ous course. In the first instance there will be a slight fever, 
cough, which at first is dry and irritating in character, later 
becoming loose and accompanied by rattling of mucus in the 
larger tubes. Some soreness in the region of the bifurcation 
of the trachea may be present, but the child evinces no great 
degree of pain or discomfort, and within a week or less the 
attack is over. 

When the smaller tubes, however, become involved, the 
case presents an entirely different aspect. There is marked 
dyspnoea, imperfect aeration of the blood and enfeebled circu- 
lation, higher fever (103 to 104 F. or over), and the chest 
abounds in subcrepitant and sibilant rales, besides coarse 
rales of mucus in the larger tubes. The child is exhausted 
from incessant cough and carbonic acid poisoning, and the 



262 DISEASES OF CHILDREN. 

cough is too feeble to expel the mucopurulent secretion 
blocking the air-vesicles and bronchioles. It becomes dull 
and apathetic, even comatose, the pulse rapid and thready or 
imperceptible, and death, sometimes preceded by convulsions, 
terminates the scene. 

This severe type, described as capilliary bronchitis, is, 
strictly speaking, a broncho-pneumonic process, and it is im- 
possible to draw a sharp line of distinction between an acute 
spreading bronchitis and a pneumonia. As stated above, the 
pulmonary parenchyma soon shares in the inflammatory pro- 
cess both through continuity and contiguity of structure and 
therefore these cases present bronchitis, peribronchitis and 
lobular inflammation. 

Diagnosis. — In bronchitis the percussion-note never be- 
comes altered unless emphysema, atelectasis or other com- 
plications develop during its course. In mild cases there are 
at first dry rales, followed by large moist rales, with here and 
there a sibilant and small moist rale, all best heard pos- 
teriorly. In the second variety subcrepitant and sibilant rales, 
general in distribution, with large moist and dry rales in the 
large tubes and trachea, and areas of dullness, with dimin- 
ished respiratory murmur, indicating collapse of air-cells, may 
be elicited. Hyper-resonance, resulting from vicarious em- 
physema, is difficult to identify in children, as the normal 
percussion-note is in itself highly resonant. 

Sufficient dilatation of some of the bronchi (bronchiectasis) 
to produce physical signs may result. In such cases bronchial 
breathing may be heard over the dilated bronchus and a 
tympanitic note can be elicited by percussion. The sputum 
is purulent and separates into a purulent sediment superim- 
posed by a fluid and frothy layer. 

Treatment. — In mild cases of bronchitis it is often ad- 
visable to keep the child out in the fresh air as much as pos- 
sible, instead of rigid confinement to the bed or nursery. The 
predisposition to bronchitis must be overcome by cold spong- 
ing, plenty of out-of-door exposure, and the correction of the 



DISEASES OF THE RESPIRATORY TRACT. 263 

underlying diathetic condition with appropriate remedies and 
diet, fat being especially beneficial. 

Severe cases of bronchitis should receive all the care and 
attention accorded a case of pneumonia. 

Remedies are numerous, the most useful, however, judging 
from the frequency of their successful employment, being 
Aeon., Bell., Bry., Ipecac, Merc., Puis., Rhus tox., Tartar 
emetic and Sulphur. 

Beside these the Calcareas, Cham., Ferritin phos., Hepar, 
Hyos., Lycop. and Phos. are often indicated in individual 
cases. 

In the early stages Aeon., Bell., Bry., Cham., Ferrum phos. 
and Mercurius must be differentiated. 

Aconite has high fever, dry skin, no chilly feelings as in 
Mercurius, nor disposition to moisture of the skin, as in Bel- 
ladonna, which has a dry, distressing, paroxysmal cough, 
usually worse towards evening. Belladonna is looked upon 
by some as a specific. The old school resort to its use 
largely. Its usefulness cannot be disputed, but I see no 
reason for pushing the drug to its full physiological action. 

The greatest usefulness for Bryonia seems to be to loosen 
the cough when the same shows no disposition to become 
so, remaining deep and hollow, apparently coming from the 
epigastric region, aggravated by motion and often accom- 
panied bypain. Scilla is also strongly indicated by painful 
cough ; it is, however, a more severe type than Bryonia, there 
being cyanosis and failing circulation, owing to extension 
of the process into the finer tubes. 

Cham, suits mild cases of tracheo-bronchitis in the early 
stages ; the cough is excited by attempting to use the voice, 
and the child is fretful and cross. 

Ferrum phos. — Often preferable to Aconite in cases charac- 
terized by marked dyspnoea right from the beginning, with 
rapid progress, soon assuming the capillary variety. The 
cough is short and dry, often paroxysmal, and when expec- 
toration appears it is streaked with bright blood. Well 
suited to rachitic subjects. 



264 DISEASES OF CHILDREN. 

Mercurus. — " Mercurius corresponds with the whole course 
of a severe attack of bronchitis, even better than Belladonna. 
There is a violent fever, the temperature is very high, there 
is a great disposition to sweat without obtaining any relief 
from it ; in contradistinction to Belladonna there is a constant 
alternation of chills and heat, with a remarkable sensitiveness 
to the most trifling changes of temperature (B^Ehr, Science of 
Therapeutics)" Tongue thickly coated yellow ; diarrhoea ; 
cough dry, worse evening until midnight ; dyspnoea ; expec- 
toration tenacious. 

Lobelia inflata. — "Think of lobelia in asthenic bronchitis 
of children with profuse secretions, and difficulty in removing 
the accumulations; also if there is a sense of oppression and 
feeling of dulness." ^Medical Advance" July, 1898, 
T. G. Roberts.) 

As the cough becomes loose, Ipecac, Pulsatilla aud Tartar 
emet. or one of the Calcareas will be required. For the 
therapy of the severe types and complications the reader is 
referred to the article upon Broncho-pneumonia. 

In a case of pseudo-mt mbranous bronchitis I obtained ex- 
cellent results from Phos. 

CHRONIC BRONCHITIS. 

Chronic bronchitis may result from repeated attacks of 
acute bronchitis, or, more commonly, follow upon an at- 
tack of whooping-cough, measles, or other acute illness, in 
w T hich there is offered predisposition to the development of 
bronchitis. In infants, rickets or simple malnutrition lay 
the foundation for chronic bronchitis, while in older children 
the scrofulous diathesis is found. As a secondary disease, 
it accompanies tuberculosis, organic heart disease and Bright's 
disease. 

The important pathological conditions are thickening of the 
mucous membrane, with areas of superficial ulceration, weak- 
ening and irregular dilatation of the bronchial tubes, and 
more or less extensive vesicular emphysema. 



DISEASES OF THE RESPIRATORY TRACT. 265 

The important symptoms are cough and expectoration, the 
characteristic condition being, that notwithstanding the long 
continuance of these symptoms, the general health rarely suf- 
fers to a marked degree. Naturally, these children are not 
up to the normal standard of health, as the etiology of the 
affection indicates; at the same time there is no pronounced 
wasting or suffering induced by the disease. 

The cough is loose, usually paroxysmal, and may become 
dry and teasing at times. It is generally worse in the morn- 
ing, and the expectoration of large quantities of offensive 
muco-pus on rising, associated with localized gurgling rales, 
is strongly indicative of bronchiectasis. 

The course is a slow one at the best, and cases may be 
apparently cured in the summer only to have a relapse during 
the winter. Nevertheless, the prognosis is good, the condi- 
tion being much more amenable to treatment than in adults 
for the reasons that the tissues are more regenerative and the 
disease less frequently dependent upon an incurable associated 
condition. 

Treatment. — An equable, moderately warm and dry climate 
is desirable; the mountainous pine regions are especially 
beneficial. Tonic treatment must be instituted in all cases 
— baths, fresh air, exercise and a highly-nutritious diet being 
the essentials. 

Of the greatest importance in these cases it is to search for 
and correct any abnormality in the nose and throat. Septal 
deflections, spurs and polypi are frequent sources of irritation 
but more commonly adenoids and enlarged tonsils will be 
found Enlargement of the lingual tonsil is often responsible 
for persistent winter coughs and should be looked for. 

Hepar sulph. I have found of especial benefit for the par- 
oxysmal cough coming on at night. A powder of the second 
or third decimal trituration will usually relieve these attacks 
with astonishing promptness. 

Pulsatilla, of course, is indispensable for the loose cough 
with profuse easy expectoration of yellowish or yellowish- 
18 



266 DISEASES OF CHILDREN. 

green muco-pus, having a tendency to become tighter and 
more troublesome at night. This remedy acts very satisfac- 
torily with Hepar, and I frequently employ it during the day, 
giving a dose of Hepar at night. 

Lycopodium is particularly useful for the recurrent type of 
bronchitis, in which the patient is seldom free from a trouble- 
some cough, "catching cold" on the slightest provocation. 
"Cough dry, day and night, in feeble, emaciated boys." — (C. 
WESSELHOEET.) Lyithsemic subjects; acid dyspepsia; cough 
ending with a loud belch. 

Sulphur. — Rarely will a case be found in which Sulphur 
is not at one time or another indicated. Especially in the 
scrofulous or rheumatic type of constitution will it be found 
useful. It has not proven of much use where emphysema 
was present; but where there is a large amount of tenacious 
mucus, mixed with lumps of pus, of foul taste and odor, it 
seems particularly applicable. There may also be attacks 
of oppression of breathing, in which the patient gasps for air. 

Tart, emetic. — Useful in recent cases, with loud rales in the 
larger tubes, and dyspnoea with the cough. 

The Calcareas are especially called for upon their diathetic 
indications. 

Calc. carb., beside its characteristic sweat, large belly and 
glandular enlargements, will be indicated by loose cough, 
with expectoration of yellowish, sw ? eetish mucus, or dry, 
teasing cough, with dyspnoea and palpitation of the heart 
from slightest exertion. Calc. phos. is more suited to the 
purely rachitic with diarrhota, or cases of simple malnutri- 
tion. 

Silicea. — Emaciated children, tuberculous diathesis; night- 
sweats ; profuse purulent expectoration ; skin dry and scurf}' ; 
hectic fever ; bronchiectasis ; lack of normal body-heat, with 
constant chilliness. The cough is aggravated from cold 
drinks, and is deep and distressing. 

Beside these it may be necessary to resort to one of the fol- 
lowing remedies for special conditions and symptoms : 



DISEASES OF THE RESPIRATORY TRACT. 267 

Ars. — Emphysema ; dyspnoea. 

Carbo veg. — Hoarseness ; chronic spasmodic cough remain- 
ing after whooping-cough. General loss of vascular tone of 
the entire mucous membrane of the respiratory tract. 

Iodinm. — Especially indicated in dark-complexioned, ema- 
ciated children. Ravenous appetite without a correspond- 
ing gain in weight ; enlarged bronchial glands. The Iodides 
are particularly useful in the bronchitis accompanying 
phthisis. 

Kali bichromicum. — Tough, stringy expectoration ; cough 
excited by eating. Bronchitis after measles. 

Kali hydriod. — Syphilitic cases. 

Stannum. — Bronchial dilation, with excessive purulent ex- 
pectoration ; weak feeling in chest. Stibium iodid is also an 
excellent remedy for bronchiectasis. 

ASTHMA. 

The majority of cases of asthma occurring during child- 
hood are of the catarrhal type, the asthmatic paroxysm ac- 
companying a bronchitis or broncho-pneumonia. The typical 
spasmodic type as seen in adults is rare, seldom occurring be- 
fore the sixth year, although mild asthmatic phenomena such 
as bronchial spasm, occurring with dentition ; asthma dys- 
pepticum (Henoch), due to indigestion, and hysterical asthma 
[pharyngeal spasm and hysterical tachypnea), are frequently 
met with prior to this time. 

Idiopathic spasmodic asthma is most probably a vasomotor 
neurosis intimately associated with the lithsemic diathesis, 
although the bronchial-spasm theory has still many adher- 
ents. Local irritation induced by pathological conditions of 
the nose and pharynx plays an important role as a reflex ex- 
citing cause. Personally I cannot accept any other explana- 
tion for the suffocative symptoms than that of turgescence 
and swelling of the mucosa. Asthma is, so to speak, a "hay- 
fever" of the bronchia. During attacks of asthma it has 
been possible to see the mucosa of the trachea and study its 



268 DISEASES OF CHILDREN. 

condition. Freeman has seen it so swollen in cases of influ- 
enza accompanied by great dyspnoea that the lumen of the 
trachea was almost occluded. 

Symptomatology. — The attacks occur suddenly, usually at 
night, the chief symptom being dyspnoea, accompanied by a 
dry cough and characteristic respiration. The inspiration is 
difficult, accompanied by recession of the soft parts of the 
thorax, and expiration is prolonged. The respiratory mur- 




ine;. 35.— SPASMODIC ASTHMA, ILLUSTRATING THE ACTION 

OF THE ACCESSORY RESPIRATORY MUSCLES AND 

THE DISTENTION OF THE LUNGS. 

inur is diminished, and the chest abounds in sibilant and 
sonorous rales ; wheezing may be heard at quite a distance 
from the patient. Cyanosis becomes pronounced if the attack 
is a prolonged one. The attacks may last from a few min- 
utes to an hour or more, and generally cease suddenly with 
a free secretion from the bronchial tubes ; they recur at in- 
tervals of days or weeks. 



DISEASES OF THE RESPIRATORY TRACT. 269 

The catarrhal form is only the engrafting of the asthmatic 
element upon a pre-existing bronchitis or broncho-pneumonia, 
in individuals thus predisposed. At times these children are 
subject to pseudo-croup, the asthma seemingly taking the place 
of the former. During its entire course they are always more 
or less " wheezy." 

The diagnosis depends upon a recognition of the nervous 
element in the case — the spasmodic and paroxysmal nature 
of these attacks, together with the characteristic physical 
signs of the diseases, namely, dyspnoea, cyanosis, diminished 
respiratory murmur, loud sibilant and sonorous rales, vesiculo- 
tympanitic percussion-note. When bronchitis or broncho- 
pneumonia coexist, their signs must be discounted. 

Treatment. — The same hygienic measures recommended for 
bronchitis are applicable to overcome the tendency to recurr- 
ing attacks of asthma. All foci of local irritation in the 
naso-pharynx or elsewhere should receive prompt attention. 

Of equal importance, and in some cases the sine qua non 
for a cure, is the strict, systematic supervision of the diet of 
the patient. Exercise, personal hygiene and thorough ven- 
tilation of the sleeping apartment must be insisted upon. 

The remedies most useful to mitigate the attacks are Aeon., 
Ars., Ipecac and Nux vom.; beside these there are several 
others which are often prominently indicated. The interval 
requires constitutional treatment. 

The inhalation of a spray containing a few drops of the 
tincture of Ipecac acts as a palliative during attacks. In some 
cases it is necessary to burn Stramonium leaves in order to 
make the suffering endurable. 

Aeon, is recognized by its well-known mental condition, 
feverishness, etc.; neurotic cases. 

Apis. — When the attacks seemingly follow the recession of 
an urticaria, or alternate with the same. The chest feels 
bruised, and the attack ends with the expectoration of a large 
amount of frothy mucus and serum. It is a valuable remedy 
for the asthma of children. 



270 DISEASES OF CHILDREN. 

Ars. — Paroxysms between midnight and daybreak ; must 
get out of bed ; great anguish and prostration ; broncho- 
pneumonia. 

Ars. jod. — Between the attacks. — (Bellvilxe.) 

Ipecac. — Wheezing ; constant cough, with subcrepitant 
rales all over chest ; no phlegm yields, although the chest 
seems full. Gagging and vomiting ; the child stiffens dur- 
ing the choking attacks ; cyanosis and coldness of extremi- 
ties. 

Lobelia. — In connection with disordered stomach ; weak- 
ness in pit of stomach ; attack preceded by prickling sensa- 
tion in extremities ; distressing tightness across upper portion 
of chest. 

Nux vom. — Asthma dyspepticum ; attacks in morning; 
irritability and constipation. 

Pulsatilla. — Cough, becoming dry toward night, with 
dyspnoea ; inability to lie down ; chilliness ; mild, tearful dis- 
position. 

Tart. emet. — Rattling of mucus in larger bronchial tubes, 
with wheezing, great dyspnoea, and threatened collapse. 
This is a most valuable remedy for the catarrhal form of 
asthma, when there is a large secretion of mucus, together 
with pronounced dyspnoea. 

ACUTE BRONCHO-PNEUMONIA. 

Broncho-pneumonia, also described as catarrhal and lobular 
pneumonia, is one of the most common diseases of childhood, 
presenting a mortality rate only exceeded by diarrhceal dis- 
eases, and being particularly prevalent before the fourth year 
of life. As the name indicates, it is a pneumonic process as- 
sociated with inflammation of the bronchial tubes, in reality 
an extension of the latter condition into the walls of the 
terminal bronchi and surrounding end alveoli. 

Etiology. — A primary and a secondary broncho-pneumonia 
are to be distinguished. Primarily broncho-pneumonia occurs 
with especial predilection in those debilitated by previous ill- 



DISEASES OF THE RESPIRATORY TRACT. 271 

nesses, or in the rachitic and syphilitic. Atmospheric 
changes are the chief exciting cause, as the greater prevalence 
of this disease during the winter months and early spring 
clearly indicates. Primary broncho-pneumonia is rarely seen 
after the fourth year, being practically a disease of early 
childhood. 

Secondary broncho-pneumonia accompanies and compli- 
cates the acute infectious fevers, prominently the exanthe- 
mata, diphtheria, whooping-cough and influenza, a class of 
diseases in which bronchitis is a frequent accompaniment. 

The latest bacteriological researches indicate that primary 
broncho-pneumonia is nearly always due to the pneumococcus, 
while secondary broncho-pneumonia results from a mixed in- 
fection, in which the streptococci of suppuration play the most 
important role When complicating diphtheria the Klebs- 
Lbffler bacillus is the excitant of the pathological process. 
Pearce (Jour. Boston Soc. Med. Sciences, June, 1897) found 
in sixty-two cases of this class the Klebs-Loffler bacillus fifty- 
two times, the streptococcus pyogenes twenty-seven times, 
the staphylococcus pyogenes aureus eleven times, staphylo- 
coccus pyogenes albus once, pneumococcus once. In seven- 
teen cases the Klebs-Lofner bacillus occurred alone ; in seven 
the streptococcus pyogenes. In the other cases there was almost 
always a combination of these varieties, with, however, a pre- 
ponderance of the cocci. In summing up, he remarks that 
where a local or general infection existed the pneumonia was 
due to the same micro-organism, but where the condition was 
a chronic or non-infectious process it was generally due to the 
pneumococcus. The investigations of Prudden and North- 
rup (Amer. Jour. Med. Sciences, June, 1889), and those of 
Neuman (Jahrbuch fiir Kinderheilk., vol. xxx., 1889), and 
others practically lead to the same conclusions. In pure 
pneumococcus cases the temperature is generally uniformly 
high, while in those due to the streptococcus wide fluctua- 
tions in the fever are more likely to occur. 

The etiological relationship of influenza to broncho-pneu- 



272 DISEASES OF CHILDREN. 

monia has been carefully studied by Prudden (Influenza and 
its Complicating Pneumonia, New York Med. Record, 1890) 
and Weichselbaum {Wiener Klin. Wochenschr., 1890). 

Pathology. — In the larger bronchi we encounter a super- 
ficial inflammation, while in the smaller tubes the entire wall 
shares in the pathological process, and we find here both 
bronchitis and peribronchitis The characteristic lesions are 
in the air vesicles, which in typical cases are distended 
with cellular exudation. The cells are mainly swollen, des- 
quamated epithelia with small nuclei. Red blood corpuscles 
and leucocytes are also found in variable number. Fibrin as 
a rule is scant ; often entirely absent. The fibrin in these 
cases is difficult to demonstrate, as the threads are rendered 
indistinct through the presence of a large number of leu- 
cocytes. (Zeigler.) 

In the alveolar septa and peribronchial connective tissue 
the blood vessels are distended with red blood corpuscles and 
these structures are infiltrated with large mononuclear leu- 
cocytes. 

Taking into consideration the above histological changes 
in the pulmonary tissue it is clear why resolution is slow and 
why often it is delayed, leading to permanent tissue changes. 
On account of the coexisting bronchitis in the finer tubes, it 
is clear also why in the presence of much mucous secretion 
suffocative symptoms may arise (capillary bronchitis). 

It may happen — and this is not uncommon during the sec- 
ond and third year of life — that a mixed form of pneumonia 
develops, in which one portion of the lung is the seat of typi- 
cal catarrhal and interstitial inflammation while another por- 
tion is consolidated by purely croupous exudation without 
involvement of the alveolar walls and peribronchial tissue. 
These cases pursue more closely the clinical course of broncho- 
pneumonia than lobar pneumonia, but it requires microscopic 
examination to recognize the true character of the lesions. 

Frequently small broncho-pneumonic areas representing 
consolidated alveoli may spread and become confluent, thus 



DISEASES OF THE RESPIRATORY TRACT. 273 

invading an entire lobule and giving rise to a lobular pneu- 
monic process. These lobular areas are in the majority of 
cases separated by streaks of uninvaded lung tissue, /'. e. y 
lobules still pervious to air. An entire lobe may, however, 
become invaded, in which case we are confronted with a 
broncho-pneumonia of lobar distribution. (Zeigler.) 

The exudate in some instances is haemorrhagic in charac- 
ter. When resolution is delayed it frequently becomes puru- 
lent owing to the presence of a large number of leucocytes 
that have undergone degeneration. 

Although the inflammatory process may become general, as 
is the case in bronchitis, still pneumonia tends to localize 
itself, in this way differing from the former condition. A 
localized lesion, therefore, is either pneumonia or tubercu- 
losis, and rarely, if ever, bronchitis. Again, the temperature 
is higher and more persistent in pneumonia than in bron- 
chitis. 

As Holt points out, the term broncho-pneumonia is a gen- 
eric one. It is therefore impossible to describe the entire 
group by a single case, even though such a case present the 
leading features common to this group of pulmonary inflam- 
mation. Broncho-pneumonia on the one hand may abort in 
the early stage before consolidation can be detected and thus 
run the course of a severe bronchitis, while on the other it 
may assume the characteristics of a lobar pneumonia. 
Again, instead of undergoing resolution the inflammatory 
process may continue and interstitial pneumonia be the re- 
sult. 

The pathological findings are by no means uniform and as 
Delafield has pointed out the consolidated lobules may bear 
no definite relationship to the bronchus leading to them. 
The inflammation is diffuse in character, and lobule after 
lobule may become consolidated without its communicating 
bronchus being simultaneously involved. The inflammation 
therefore travels through contiguity of structure as well as by 
continuitv thereof. 



274 DISEASES OF CHILDREN. 

In the early stage (red pneumonia) the lung is engorged 
and of an intense red color. On section, a bloody, frothy 
fluid exudes from the air cells. The bases are heavier and 
darker in color owing to hypostatic congestion. Consolida- 
tion has not yet taken place, but microscopic examination 
reveals cell-proliferation in the peri-bronchial connective 
tissue and septa and catarrhal and hsemorrhagic exudate in 
the alveoli. The process may abort here, prove fatal, or go 
over into the stage of mottled or red and gray pneumonia, 
representing the fully developed process. By this time the 
consolidated areas may be felt as small nodules in the pul- 
monary parenchyma. Both the surface and the sections pre- 
sent a mottled appearance due to the admixture of consoli- 
dated (gray) and congested (red) areas. The process may 
involve an entire lobe or appear only in patches dispersed 
through the otherwise normal lung tissue. Wherever a 
bronchus has become occluded areas of atelectasis are seen. 
Such areas correspond always to a bronchus, but consolidated 
lobules, as has been pointed out above, do not. 

If resolution be delayed or arrested^ the so-called gray pneu- 
monia is the result. In these cases the lung is somewhat en- 
larged, gray in color and extensively consolidated. Pleural 
thickening and adhesions are common. On section a muco- 
purulent exudate covers the cut surface. The bronchial 
walls and the interstitial tissue are hyperplastic and areas of 
atelectasis and compensatory and interstitial emphysema lie 
interspersed between the consolidated structure. 

In the cases that recover the termination is resolution 
through expectoration and resorption of the exudate ; in un- 
favorable cases suppuration ; interstitial induration ; gangrene. 

Resolution may begin before consolidation can be detected. 
Ordinarily it is completed in from two to three weeks. When 
delayed, there is a strong tendency to incompleteness of the 
process. In recurring attacks, permanent interstitial changes 
are produced as a rule. Tuberculosis may be engrafted upon 
a pneumonia secondarily. 



DISEASES OF THE RESPIRATORY TRACT. 275 

The pleura shares in the inflammatory process when the 
lesions are superficial. Fibrinous and fibro-purulent exudate 
is poured out upon the surface of the visceral pleura with the 
consequent development of adhesions and thickening. In 
some instances the pleuritic process is of equal moment with 
the pulmonary ; these cases are described under a separate 
heading (see Pleuro-pneumonia). 

Symptomatology. — Primary broncho-pneumonia begins 
as a bronchitis in the majority of cases ; exceptionally the 
pulmonary changes develop at the same time or prior to, or 
even independently of, the former. Instead of advancing 
favorably as an uncomplicated bronchitis, there are added 
progressively increasing dyspnoea and rapid breathing, in- 
crease in fever and pulse-rate, and prostration. 

Some cases begin abruptly with high fever, rapid breathing 
and pronounced nervous disturbances (toxaemia). They may 
prove fatal before any signs of pulmonary inflammation have 
had time to develop ; even cough may be absent. At the 
autopsy the lungs are found intensely congested and more or 
less cedematous. 

In young infants broncho-pneumonia may come on insidi- 
ously, fever being slight during the entire course. The main 
symptoms are cough and progressively increasing cyanosis 
and rapid respirations. As a rule, gastro-intestinal symptoms 
accompany the pneumonia. The prognosis is grave. 

During the progress of the disease the child emaciates 
markedly and caibonization of the blood becomes apparent. 
The pulse is rapid and weak, and the heart may eventually 
fail in its work if the pulmonary obstruction be extensive. 

Cough is a prominent symptom, at first being dry and later 
becoming loose, although this by no means indicates that the 
child is gaining relief, for the secretion may be beyond its 
control, acting as a mechanical obstruction to the air-cells. 

The respiratory rhythm is changed in a characteristic man- 
ner, the recognition of which has always been to me a strong 
indication for pneumonia. Normally, inspiration and expira- 



276 DISEASES OF CHILDREN. 

tion follow each other without interruption, after which 
comes a pause. In broncho-pneumonia inspiration is sepa- 
rated from the expiratory act by a well-marked pause, with 
no pause, however, between the expiration and inspiration. 
The reason for this change in rhythm is undoubtedly to bring 
the inspired air in contact with the pulmonary tissue as long 
as possible in order to overcome the carbonization of the 
blood ; therefore the child rests rather before expiration than 
after it, no time being lost, thereby, to draw in a fresh supply 
of oxygen. 

Respiration is often accompanied by fan-like movements of 
the alse nasi and recession of the soft parts of the thorax, 
notably its lower portion, producing the peri-pneumonic 
groove of Harrison. 

When broncho-pneumonia develops during the course of 
one of the infectious fevers as a complication, it is to be sus- 
pected from an increase in the fever; increased rapidity of 
breathing and pulse-rate ; cough and dyspnoea, especially the 
latter. 

Broncho-pneumonia tends to localize itself in certain areas 
of the lungs, in this way differing from simple bronchitis in 
which the process is general. General bronchitis, however, 
may accompany pneumonia. In the absence of definite signs 
of consolidation, the height and duration of the fever may be 
taken into consideration. The statement Cabot makes about 
broncho-pneumonia in the adnlt, namely, that the patient is 
too sick to have simply bronchitis, applies with equal force 
to children. 

Broncho-pneumonia is progressive in its development, be- 
ing slower both in its onset and in the formation and resolu- 
tion of its pathologic products than lobar pneumonia. Its 
course sometimes extends over several weeks, and the ten- 
dency to chronicity is strong, especially in the scrofulous and 
tuberculous. 

Meningeal symptoms are of common occurrence in the dis- 
ease, sometimes being toxaemic in origin, at other times result- 



DISEASES OF THE RESPIRATORY TRACT. 277 

ing from an active congestion of the meninges with serous 
effusion into the arachnoidal spaces. Here there is always 
hyperpyrexia and a very rapid course, and rachitic subjects 
seem most prone to develop this complication. Actual men- 
ingitis from infection of the brain with pneumococci is by no 
means rare. I have found it more frequently after broncho- 
pneumonia than after the lobar form. 

Death results from respiratory or cardiac failure ; some- 
times from hyperpyrexia. Collapse is the commonest ter- 
mination, although convulsions may appear to close the sceue. 
The fulminating cases undoubtedly die from toxaemia. 

The prognosis must always be guarded, as can be seen from 
the high mortality rate ; it is especially grave when the child is 
very young and debilitated, or when the disease is secondary 
to a condition in itself dangerous. The pulse and respiration 
are the main indications of the child's condition, 3nd although 
a high temperature is a bad omen, still it is not necessarily so 
unless it is continuous and proves itself beyond control. 
Rickets seems especially likely to invite hyperpyrexia. The 
soft condition of the chest-wall in rickets makes breathing 
very difficult in pneumonia and rachitic children stand the 
disease badly. 

A grunting expiration is said to indicate atelectasis, but it 
is not necessarily a bad symptom, unless very pronounced and 
persistent. The cough is also a guide to prognosis ; if it be- 
comes weak and inefficient we must expect gradual suffoca- 
tion, unless the exudation can be absorbed. 

Children in whom the tuberculous diathesis is well marked 
are liable to the most serious consequences from an attack of 
broncho-pneumonia. An ordinary broncho-pneumonia will 
become tedious ; the temperature remits, leading us to 
suspect a possible malarial condition, but the case conti- 
nues, in spite of our best-directed efforts, toward a fatal 
termination. Primary tuberculous broncho-pneumonia is of 
slower onset and the temperature seems out of proportion to 
the physical signs that can be elicited. Besides, the tubercle 



278 DISEASES OF CHILDREN. 

bacillus can be demonstrated in these cases. As infection 
generally spreads from the bronchial glands, the presence of 
subcrepitant rales localized in the region of the nipple on 
either side indicate the presence of lesions of this nature and 
offer strong presumptive evidence of tuberculosis. (Holt.) 

Diagnosis. — The physical signs are those of both bron- 
chitis of the larger and smaller tubes, together with consoli- 
dation of scattered areas of pulmonary tissue of varying size 
and extent. They are best studied posteriorly, the child be. 
ing held over the nurse's shoulder. Large and small moist 
rales ; subcrepitant rales ; tubular breathing and dullness 
over the consolidated areas large enough to convey these 
signs ; diminished breathing over areas of atelectasis, and ex- 
aggerated breathing in the vicariously emphysematous lung 
are to be elicited. However, the irregular fever, dyspnoea, 
alteration in the respiratory rhythm and cough, and the de- 
tection of subcrepitant rales and areas of tubular breathing 
are usually quite sufficient, and often the only available signs 
upon which the diagnosis can be made. 

From croupous pneumoiiia it is distinguished by its gradual 
onset, tedious course, bilateral distribution, and its occurrence 
in the very young and in the feeble, croupous pneumonia at- 
tacking those in apparently good health and of maturer age. 
The differentiation from tuberculosis has been given above. In 
capillary bronchitis there are fine moist rales generally dis- 
tributed throughout the chest. There is, however, no sharp 
line of demarcation between the pathology of the two affec- 
tions. 

Treatment. — The child should be put to bed, and its posi- 
tion changed regularly to avoid adding hypostatic congestion 
to the already seriously crippled condition of the lungs. In- 
fants can be taken up by the nurse during coughing parox- 
ysms and held face downwards or on the side to facilitate the 
expulsion of the phlegm. The room must be faithfully ven- 
tilated, and a temperature of about yo° F., or slightly lower, 
is to be maintained. Beside this, it is essential to keep the 



DISEASES OF THE RESPIRATORY TRACT. 279 

air moist in the immediate vicinity of the child, which is best 
accomplished by means of the croup-kettle or steam spiay and 
a tent improvised over the bed. 

Ordinarily, the fever is within the control of remedies and 
sponge-baths ; indeed, an alcohol sponge-bath (one part alco- 
hol to three parts of water) has a most decided effect upon 
the temperature, rapidly bringing it down to within a safe 
limit, at which point it is maintained for an hour or more. 
In fulminating cases, or such as do not respond to the above 
treatment, the graduated cold, full bath will be required. 
This is often a life-saver, not only reducing high temperature 
but also relieving pulmonary congestion and acting in a de- 
cidedly stimulating manner upon the heart and respiratory 
centres. When carbonization of the blood becomes manifest 
and the bronchial tubes become clogged with secretion, the 
alternate application of hot and cold packs to the chest 
should be resorted to. This is a most powerful respiratory 
stimulant besides acting as a derivative and relieving pul- 
monary engorgement. 

Oxygen inhalations should never be neglected in serious 
cases. The mistake is to look upon oxygen merely as a 
dernier ressort ; given in time, however, it is a powerful 
agent to save life. I give from one to two gallons (bagfuls) 
every hour, administered by holding a glass funnel attached 
to the tube from the water-bottle of the apparatus over the 
child's mouth and nose. I prefer this to a mask or inserting 
a glass tube into the nostril. 

Plain woolen underwear, the weight conforming to the 
time of year, is all that is necessary to protect the chest, 
which, witli the rest of the body, should be regularly sponged. 

Stimulants can rarely be dispensed with, and they will be 
called for during certain periods in all bad cases. Above 
all, every effort must be made to keep up the nutrition of 
these little patients. 

The remedies most frequently indicated in the early stages 
are Aeon., Hell., Bry, t Ferrum pJws., Ipecac and Scilla; for 



280 DISEASES OF CHILDREN. 

the later manifestations, especially the unfavorable symptoms 
likely to arise, Tartar emetic, Phos., Arsen., Car bo veg. and 
Veratrum alb. are called for. 

Aconite should always be studied in comparison with Ver- 
atrum viride and Ferrum phos. All three are indicated early 
in the disease, when there is high fever and a teasing cough, 
with little or no expectoration — the stage of congestion. 
Aconite is distinguished by its great anxiety and restlessness, 
thirst, and aversion to being touched or moved, which in- 
duces suffering ; Veratrum viride by its high arterial tension, 
bloodshot eyes and cerebral irritation ; Ferrum phos. by the 
absence of either nervous erethism or high arterial tension 
and by its characteristic frothy, blood-streaked expectoration. 
It is particularly applicable to the rachitic diathesis. 

Arsenicum is indicated by extreme prostration and rest- 
lessness ; dyspnoea from the slightest exertion ; thirst for 
small quantities of water, the mouth being dry and the tongue 
and lips cracked ; diarrhoea ; cold surface. 

Belladonna is particularly valuable when nervous disturb- 
ances are pronounced. Its excellent effect in capillary bron- 
chitis makes us think of it in pneumonia when the bronchial 
symptoms predominate. In oedema of the lungs Atropia is 
the sheet anchor. Belladonna is exquisitely homoeopathic to 
the vascular engorgement and high temperature so prominent 
in many cases. 

Bryonia is of the greatest service to loosen the cough, con- 
trol pain, and check the extension of the process into the 
smaller tubes and promote the absorption of the exudation. 
It must be differentiated fiom Scilla, which is similar in 
many respects, but more suitable to grave cases marked by 
progressively-increasing prostration and dyspnoea ; rapid, 
weak pulse; short, painful cough, causing the child to cry 
faintly after each paroxysm ; in fact, it cannot be moved 
without giving it pain. In my experience, the younger the 
child, the more efficacious has been this remedy. Hale {Prac- 
tice of Medicine) considers Scilla the remedy above all others 



DISEASES OF THE RESPIRATORY TRACT. 281 

after Aconite and Belladonna, being in every respect homoeo- 
pathic to broncho-pneumonia. 

Chelidoninm is recommended where the right side is chiefly 
affected, with associated hepatic disturbances. It has the fan- 
like motion of the alse nasi so strongly indicative of Lycopo- 
dinm. Personally I have no experience with it. Dr. Bigler 
considered Chelidoninm very useful in capillary bronchitis. It 
was recommended by Teste as a specific. 

Gelsemium. — Broncho-pneumonia complicating influenza ; 
after sudden checking of perspiration; pain under scapulae; 
drowsiness; soft, rapid pulse. 

Ipecac, is the remedy where the bronchial element predom- 
inates and the chest seems literally filled with mucous secre- 
tion, subcrepitant rales being heard everywhere in abundance. 
The cough is troublesome and gagging, giving little relief. 
The secretion gradually collects to such an extent in the finer 
bronchi that suffocation becomes imminent. Here it differs 
from Tartar emetic, which represents a state of carbonic acid 
poisoning, in which mucus, collecting in the larger tubes, pro- 
duces the characteristic rattling, or in which there is active 
pulmonary oedema. 

Lycopodium is useful in broncho-pneumonia, its particular 
sphere being, so to speak, a u choked-up ,, condition of the 
entire respiratory tract. The nose is obstructed ; the alse 
nasi expand with each inspiration, which is often a purely 
sympathetic condition, not dependent upon marked dyspnoea. 
The cough is dry day and night, a few moist rales and some 
wheezing being heard over the sternum ; swelling of the 
mucous membrane of the bronchi seems to predominate over 
secretion. Likewise the lungs may be much involved, with- 
out, however, much cough or secretion. The child is peevish 
and irritable, especially on awaking from sleep; the urine is 
scanty and deep red. and when passed often induces crying; 
all symptoms are worse in the afternoon and early evening. 

Phosphorus. — Where consolidation predominates over the 
bronchial symptoms, together with active congestion, produc- 
19 



282 DISEASES OF CHILDREN. 

ing a tight, distressing cough; rapid, shallow respirations; 
tightness across the upper portion of the chest; blood-tinged 
expectoration ; failing right heart. We are inclined to think 
of Phosphorus only in lobar pneumonia, but it is of equal 
value in the lobular variety when we have to deal with con- 
gestion, consolidation and toxaemia; in fact, the old school 
has for a long time prescribed Phosphorus as a nerve tonic in 
the adynamia of pneumonia. 

Sulphur is similar to Phosphorus in respect to the consoli- 
dation, but it has a greater power of removing the same, 
Phosphorus mainly controls the vascular disturbance (unless 
pushed to produce fatty degeneration of the inflammatory 
products, which is not without danger). It is indicated in 
the later stages of broncho-pneumonia. 

Tuberculin (Koch) has been highly recommended for bron- 
cho-pneumonia. Dr. Mersch {Jour. Beige cPHom., 1894 and 

1895) reports several cases in which relief was rapidly ob- 
tained from the sixth dilution. Dr. Arnulphy {Clinique, Feb., 

1896) makes strong claims for the efficacy of Tuberculin in 
broncho-pneumonia, placing it above such remedies as Ipecac. , 
Iodine, Tartar emetic and Phosphorus, Bacillinum (Burnett) 
is recommended by Cartier {Traits. Internal. Horn. Cougr., 
1896) in respiratory affections characterized by oppression and 
muco-purulent expectoration; the dyspnoea results from pul- 
monary obstruction, caused by excessive secretion in the 
bronchi In his opinion, these cases are non-tuberculous. 
He recommends the thirtieth potency, one dose every two to 
three days. Aviare, or Avian tuberculin, he has found use- 
ful in broncho-pneumonia following influenza and measles, 
accompanied by an incessant tickling cough, with closely 
localized pulmonary symptoms and emaciation — suspicious 
bronchitis — which causes apprehension of tuberculosis. Per- 
sonally I have no experience with these products. It has 
seemed to me unnecessary to call upon such uncertain agents 
in the face of the all-sufficient array of well proven and veri- 
ified remedies at our disposal. It is true, in tuberculosis a 



DISEASES OF THE RESPIRATORY TRACT. 283 

serum may yet be prepared that will give positive results, but 
so far there is nothing absolutely certain with which I am ac- 
quainted. 

CROUPOUS PNEUMONIA. 

Croupous, or lobar pneumonia, is a primary acute infectious 
disease in which one or more of the pulmonary lobes are con- 
solidated by a croupous exudation. Bronchitis may be asso- 
ciated, but it is not an essential condition as in broncho-pneu- 
monia ; besides the infection arises, so far as can be deter- 
mined, primarily within the alveoli, being due to a specific 
micro-organism. 

Etiology. — Croupous pneumonia is most frequently seen 
after the third year, and usually attacks those of previously 
good health, unlike broncho-pneumonia, which attacks with 
predilection those already debilitated or develops in conjunc- 
tion with the acute infectious diseases. Exhaustion and ex- 
posure to cold act prominently as predisposing causes, for 
which reason genuine pneumonia is often seen to follow upon 
active play in cold weather when boys are likely to become 
overheated or become chilled from neglecting to dress prop- 
erly. While the dry, cold months, particularly the early 
spring, furnish the largest number of victims, still pneumonia 
may be seen at any time of the year, like all other infectious 
diseases. Boys are more often attacked than girls, no doubt 
because they expose themselves more than the latter. 

The sputum of pneumonia patients was long known to 
contain micro-organisms in abundance, but it was not until 
Fraenkel, in 1886, demonstrated the lance-shaped diplococ- 
cus named after him that the specific cause of the infection 
became established. Since then, however, it has been proven 
that other micro-organisms also may set up croupous inflam- 
mation in a pulmonary lobe or portion thereof. They are 
notably the pneumobacillus of Friedlander, the influenza 
bacillus, the typhoid bacillus and the staphylococcus and 
streptococcus. I have encountered the typhoid bacillus prac- 



284 DISEASES OF CHILDREN. 

tically in pure culture in a case of pneumonia complicating 
typhoid fever. The influenza bacillus may associate itself 
with the pneumococcus and render the course of the disease 
more virulent and irregular. Jousset {Revue Horn. Francaise, 
June, 1 901) has contributed most interesting observations to 
the literature of this subject. 

The pneumococcus is found in great abundance in the 
alveolar exudate and may enter the general blood current, 
setting up a septico-pyema or localized complications, notably 
pleural, meningeal and peritoneal inflammation. 

Pathology. — In typical cases of croupous pneumonia one 
lobe is affected throughout its entirety. The most frequently 
consolidated lobe is the left lower; next in frequency come 
the right lower and the right upper lobes. The right mid- 
dle and the left upper are least often attacked. 

More or less plastic pleurisy is always associated, as is also 
bronchitis of the larger tubes. Membranous bronchitis seems 
at times to be due to the pneumococcus ; I have seen it asso- 
ciated with pneumonia in one instance. When the left lower 
lobe is affected and the pleura is involved the process may 
spread to the pericardium. The pleural inflammation may 
become so prominent as to influence notably the clinical 
course of the disease. 

At the onset of pneumonia, the stage of engorgement, the 
affected lobe is bright red, greatly congested and somewhat 
cedematous. The lung appears enlarged, as if inflated, and 
when the inflammatory exudate tills the alveoli and solidifies* 
the consolidated lobe is actually larger than normal, for which 
reason the area of d illness elicited by percussion may be 
of greater extent than the lobe normally occupies. 

On microscopic examination the alveoli appear engorged, 
the bloodvessels encroaching upon the lumen of the same. A 
small amount of serum and leucocytes is now poured out, the 
exudation becoming more and more rich in cells and fibrin 
and more hemorrhagic in character. It is at this time that 
the crepitant rale is most clearly heard. The alveoli eventu- 



DISEASES OF THE RESPIRATORY TRACT. 285 

ally are distended to their utmost with red and white blood 
corpuscles and micrococci embedded in a stroma of fibrin. 
The fibrin also fills the lymphatics in the interstitial connect- 
ive tissue, and it can be seen communicating by thin bands 
through the pores of the alveoli. This period represents the 
stage of red hepatization. 

The color of the lung gradually passes from red over into 
gray, owing to the compression of the bloodvessels of the al- 
veoli by the exudate and to the degeneration of the cellular 
elements. This represents the stage of gray hepatization. 
The exudate is now gradually removed by the lymphatics, 
some being expectorated after having undergone softening, 
and resolution is in progress. In normal cases resolution is 
complete and the lung is restored to its former condition. 

During consolidation the lung is quite friable and cuts like 
liver. On the surface of the section small plugs of hardened 
fibrin filling the alveoli and independent therefrom are seen, 
giving it a granular appearance. In children this does not 
show as typically as in adults, owing to the lesser develop- 
ment of the air cells. At times, owing to a gradual spread of 
the process, all stages, that is, red and gray hepatization and 
beginning resolution, may be encountered in a cut of a single 
lobe. 

When resolution is delayed it may terminate in suppura- 
tion with abscess formation, gangrene, caseation. Complete 
recovery is, however, the rule, excepting in cases complicated 
with pleural inflammation, in which it is quite common for 
an empyema to develop secondarily. 

Symptomatology. — The onset of croupous pneumonia is 
rapid, and the course of the disease is characterized by its 
acuteness throughout; sudden onset, high temperature, with 
but slight remissions and terminating within from six to eight 
days by crisis, are the features of a typical case (Fig. 36). 

The initial symptom is characteristically a chill, which may 
be replaced by a convulsion in young children ; sometimes 
vomiting is the sole symptom. The temperature rises rapidly, 



286 



DISEASES OF CHILDREN. 



soon reaching a height of 104 or over ; the pulse is rapid and 
full, and the respirations are notably increased, exceeding the 
normal ratio between pulse and respiration. Thus, with a pulse 
of 130 there will be 60 or more respirations, while the normal 
ratio is one respiration to four heartbeats. The temperature 
ranges between 102. 5 and 104 F. or over. Remissions are 
more pronounced than in adults. 

Associated with the fever there is restlessness; dry, hot 
skin ; headache and some delirium toward night, and a dry, 




DayqfDia / 



FIG. 36. — TEMPERATURE CURVE IN A TYPICAL CASE OF 
EOBAR-PNEUMONIA, SHOWING PSEUDO-CRISIS. 



painful cough. Especially when there is considerable in- 
volvement of the pleura does this painful cough become con- 
spicuous, it being very sharp and located at the seat of the in- 
flammation. At times the pain is referred to the epigastrium, 
in which case it is due to irritation of the intercostal nerves, 
or it may indicate a complicating pleurisy or pericarditis. 
Pain in the right iliac region may also be complained of in 
pneumonia of the right base. When a child complains of 



DISEASES OF THE RESPIRATORY TRACT. 



287 



abdominal pain during the course of a febrile attack we 
should never neglect to thoroughly examine the chest. 

Within from two to four days the process of consolidation 
is generally complete, as can be demonstrated by the dulness 
and bronchial breathing observed over the affected area. 
With the crisis, which may appear on any day from the fifth 
to the ninth, oftenest, however, on the seventh day, there is a 
marked amelioration of all symptoms. A profuse sweat ac- 
companies this sudden fall in temperature, and at times, in- 




FIG. 37.— TEMPERATURE CHART OF A CASE OF 
REMITTING PNEUMONIA. 



deed, there occur quite alarming symptoms of collapse, calling 
for immediate action. After the crisis the process of resolu- 
tion becomes established, being completed in from five days 
to a week in the average case. I have seen every evidence of 
dulness and bronchial breathing disappear within three days 
after the crisis. A rise of temperature during this time— in 
other words, a post-critical rise — indicates the development of 
some complication, such as pleurisy, empyema, meningitis, 
pericarditis or the extension of the pneumonic process to 



288 DISEASES OF CHILDREN. 

other portions of the lungs. A pseudo-crisis is common in 
children. It may occur as early as the second day, more 
commonly one or two days before the actual crisis. Termi- 
nation by lysis is more common in children than in adults. 
Marked remissions in the temperature are also more common 
in children than in adults. When pronounced these cases 
are described as remittent pneumonia (Fig. 37). 

The blood changes are important. While there is but a 
slight anaemia, leucocytosis develops to a marked degree. A 
pronounced leucocytosis indicates a severe infection in an or- 
ganism capable of good reaction (Da Costa). Leucocytosis 
offers a strong sign of differential diagnosis between pneu- 
monia and such conditions as acute typhoid septicaemia, case- 
ous pulmonary tuberculosis and serous pleurisy, it being ab- 
sent in these conditions. It is of no value, however, in the 
differentiation of croupous pneumonia from broncho-pneu- 
monia, empyema and meningitis (Da Costa). 

Many severe cases of pneumonia present so different a clin- 
ical picture from the group of symptoms above enumerated 
that they merit separate description, being classified into the 
following varieties : 

Cerebral pneumonia. — This form is characterized by rapid 
onset with high fever, convulsions or vomiting, and a pre- 
dominance of cerebral symptoms during the entire course of 
the disease. In other words, it is essentially a manifestation 
of pronounced toxaemia. In children over two years convul- 
sions are not so common, these cases assuming more of a 
typhoid state, there being stupor, delirium, dry, brown tongue, 
involuntary stools. Symptoms simulating meningitis, such 
as sopor, strabismus, opisthotonos, slow, irregular pulse, re- 
tracted abdomen, dilated pupils, convulsions, are a frequent 
accompaniment of pneumonia, and there seems to be a close 
clinical relationship between pneumonia of the upper lobes 
and cerebral symptoms, notwithstanding that this is disputed 
by some competent observers. The pneumonic process is 
slow to develop in many cases, and often the consolidation 






DISEASES OF THE RESPIRATORY TRACT. 289 

cannot be detected until four or five days after the onset, 
having begun centrally ; for this reason it may be confounded 
with meningitis. The writer recalls a case of croupous pneu- 
monia occurring in a child five years old which was diagnosed 
as meningitis by a most expert clinician until the detection 
of dullness and bronchial breathing in the right upper lobe 
on the fifth day, together with a disappearance of all serious 
symptoms by crisis on the seventh day, made it possible to 
recognize the true nature of the case. That these symptoms 
are toxic in nature there is little reason to doubt, but the 
possibility of a true purulent meningitis developing must 
never be lost sight of. This seldom, however, develops dur- 
ing the height of the pneumonia, a return of the fever with 
cerebral disturbance after the crisis being more likely to 
prove of serious import than the earlier manifestations. 

Another form of pneumonia worthy of mention is the so- 
called wandering pneumonia, in which the pneumonic pro- 
cess spreads from its original seat to other portions of the 
lung, resolution going on at one point while a fresh invasion 
attacks another. 

Central pneumonia is of especial interest from the diag- 
nostic standpoint, as in these cases the process begins in the 
centre of a lobe, gradually spreading to the periphery. It is 
a patent fact that they cannot be recognized until there is 
sufficient consolidation to produce physical signs, and are fre- 
quently overlooked for this reason. Grave symptoms may 
exist with but a slight amount of consolidation, the toxaemia 
being entirely out of proportion to the existing lesion. 

Pneumonia with Gastro-intestinal Symptoms. — Gaillard 
has shown that the enteric symptoms of pneumonia are due 
to the pneumococcus. Toxaemia, however, contributes its 
share in the production of pronounced gastro-intestinal de- 
rangements. I have on several occasions wrongly suspected 
intestinal auto-intoxication when the subsequent appearance 
of pulmonary signs and a crisis with amelioration of symp- 
toms cleared up the case. 



290 DISEASES OF CHILDREN. 

Influenzal pneumonia may be either due to the PfeifTer 
bacillus or result from secondary infection with the pneumo- 
coccus. These cases begin as an influenzal bronchitis, during 
the course of which one or more pulmonary lobes become con- 
solidated. The course is graver and more protracted than 
simple pneumonia. It is also liable to be followed by tuber- 
culosis. 

Abortive pneumonia is rare in children. Cases are en- 
countered which terminate in from four to five days ; they 
might be called mild cases. Again, the process may not go 
beyond the first stage, and although congestion of a single 
lobe and pneumococci in the sputum can be demonstrated, 
consolidation fails to take place, the process actually abort- 
ing, as other acute infections sometimes do. It is needless to 
say that the diagnosis is beset with great difficulty. There 
are also fulminating cases, terminating fatally in the first 
days. 

Typhoid-pneumonia. — This misleading term refers to those 
forms of pneumonia in which the patient sinks into a typhoid 
state as the result of toxaemia. Instead of active brain symp- 
toms being present as in cerebral pneumonia there is apathy 
and prostration ; dry, coated tongue ; tympanites with either 
obstinate constipation or diarrhoea ; involuntary stools ; mut- 
tering delirium ; subsultus tendinum. Rose-spots, enlarged 
spleen and Widal reaction are negative. Typhoid fever, how- 
ever, may begin as a pneumonia ; in these cases a diagnosis 
can only be made when the last mentioned signs put in an 
appearance. In doubtful cases blood cultures should be 
made. 

Pleuro-pneumonia is a form sufficiently distinct to merit 
separate discussion. 

Complications. — A certain degree of pleurisy belongs to 
pneumonia. Pletu-al effusions, both serous and purulent, are, 
more strictly speaking, sequelae ; they are much more com- 
mon in children than in adults. Otitis is common ; it always 
produces an increase in and prolongation of the fever ; not 



DISEASES OF THE RESPIRATORY TRACT. 291 

necessarily pain. Meningitis is more likely to occur after 
the critical period ; cerebral symptoms at the height of pneu- 
monia are usually toxic and do not persist. Pericarditis is a 
grave complication ; I have several times encountered it at 
the autopsy. It is seldom recognized in vitam. Other com- 
plications that may develop are endocarditis, peritonitis, gas- 
troenteritis, arthritis, septico-pyaemia. 

Physical Signs. — The physical signs in lobar pneumonia 
vary with the different stages of the pathological process. 
The duration, clinical course and complications also modify 
these signs as well as the age of the child (anatomical pecu- 
liarities). 

In Xhe. first stage inspection reveals a flushed countenance ; 
rapid, shallow respiration and more or less pronounced dysp- 
noea. When the pleura is much involved the child turns 
over on the affected side. Dyspnoea may even progress to 
cyanosis ; retraction of the supra-clavicular and supra-sternal 
regions ; recession of Harrison's groove ; fan-like motion of 
the alse nasi. 

On palpation the skin will be found hot and dry. The 
pulse is full and rapid. Vocal fremitus is not increased but 
coarse bronchial rales may be detected. 

Percussion reveals dull tympany. This can be nicely dem- 
onstrated in children by gentle percussion as the chest- wall is 
still resilient. 

We are dependent upon auscultation for a pathognomonic 
sign. This is the snbcrepitant rale — a fine, crackling sound, 
produced at the end of inspiration by the separation of the 
walls of the air cells which at this stage contain a sticky 
exudate. As these rales may remain confined to a limited 
area and disappear after several hours, they are readily over- 
looked. 

Friction rales, pleural in origin, are frequently heard. An 
interesting observation has been made by Shaw {Archives of 
Pediatrics, Aug., 1903), who found that the crepitant rale 
and friction sounds can be distinctly heard over the abdomen 
when the lower lobes are affected. 



292 



DISEASES OF CHILDREN. 



Second Stage. — With the completion of consolidation vocal 
fremitus is increased over the affected lobe and percussion 
dullness becomes pronounced. The area of dulness apparently 
covers a larger area than the anatomical boundaries of the 
lobe allow for. This is explained by the fact that the croup- 
ous process distends and enlarges the lobe. When pleural 
effusion takes place the lower portion of the dull area be- 




FIG. 38. — LOBAR-PNEUMONIA IN A CHILD FOUR YEARS OLD. 

THE DULL AREA IS OUTLINED AND CORRESPONDS TO 

THE LEFT LOWER LOBE. AT (x) FRICTION SOUNDS 

ARE HEARD; AT (O) BRONCHIAL BREATHING 

AND BRONCOPHONV. 



comes flat. It is not uncommon to hear friction sounds in 
the lower part of the chest, posteriorly and laterally, in pneu- 
monia in this region. The adjoining normal lung, through 
compensatory emphysema, may give the vesiculotympanitic 
note. 

Auscultation reveals bronchial breathing and bronchophony. 



DISEASES OF THE RESPIRATORY TRACT. 293 

The respiratory murmur in trie unaffected lung is harsh and 
loud, often greatly interfering with a proper study of the con- 
solidated area. It is undoubtedly more difficult to outline an 
area giving bronchial breathing in the child than in the 
adult. 

Third Stage. — As resolution sets in and the exudation be- 
gins to soften, crepitation reappears {crepitatio redux). Moist 
rales are usually added and considerable of the exudate is 
coughed up. Bronchial breathing persists longer than actual 
consolidation ; so also dulness. This is no doubt due to the 
congested state of the pulmonary tissue. For this reason it 
is possible to demonstrate abnormal physical signs for a week 
or longer after the crisis. We must, however, regard with 
suspicion the persistence of pronounced dulness and dimin- 
ished or absent respiratory murmur after pneumonia. Such 
a condition on closer investigation will be found to indicate 
most likely a sacculated empyema. 

The physical signs of pleitro-pneumonia are described under 
that affection. 

Prognosis. — In infants the prognosis is unfavorable. Ro- 
bust children from three to ten years old recover as a rule. 
In fact, the mortality rate at this period of life is surprisingly 
low. The season of the year and the nature of the epidemic 
affect the prognosis. The association of influenza is unfav- 
orable. 

Of primary importance in gauging the prognosis is the de- 
gree of toxaemia. This seems more important than the ex- 
tent of the pulmonary involvement or the height of the fever. 
Naturally, the spread of the disease to adjacent portions of 
the lung is unfavorable. The heart holds out better than in 
the adult because the child's circulatory apparatus can adapt 
itself to increased circulatory obstruction better than the 
adult's. The association of bronchitis, however, adds materi- 
ally to the danger of the attack. Pronounced cerebral symp- 
toms are also grave. 

The majority of deaths occur at the height of the disease. 



294 DISEASES OF CHILDREN. 

When death occurs later it is the result of one of the above 
mentioned complications. 

Diagnosis. — Whenever we are confronted with an acute 
condition of sudden onset with high fever preceded either by 
a chill, vomiting or a convulsion, we should first examine 
the throat. Finding nothing specific here it behooves us to 
examine the chest most thoroughly. 

It may be that at this early stage we may discover sub- 
crepitant rales in one of the bases or in the right upper lobe 
and possibly a friction sound. The following day, together 
with a continuance of the high temperature and in older chil- 
dren the complaint of intense headache and pain in the side 
or epigastrium, we will find the evidences of beginning pul- 
monary consolidation. Even should we not be able to dem- 
onstrate the physical signs, as in central pneumonia (rare), 
still, the sudden disappearance of all symptoms at the end of 
a week or less justifies us in diagnosing pneumonia. 

The conditions from which genuine pneumonia is to be 
differentiated are broncho-pneumonia, pleurisy, meningitis and 
caseous tuberculosis. I will not again go over the symptoms 
deciding the diagnosis. Suffice it to say, broncho-pneumonia 
is essentially bronchial in origin, both etiologically and patho- 
logically, and that its course is long and protracted, independ- 
ent of complications. In pleurisy the physical signs are 
essentially different and the onset gradual. The fever is not 
so high and terminates by lysis. Besides, primary pleurisy 
with effusion is rare in children, but pleuritic inflammation 
and the exudation secondary to pneumonia is common. 

In meningitis symptoms are continuous and protracted. 
Death is practically always the termination excepting in the 
epidemic cerebro-spinal variety. Meningitis complicating 
pneumonia occurs in the later stages of the disease ; cerebral 
symptoms occurring at the height of pneumonia are toxic 
and disappear by crisis or even before the crisis. Besides, 
they never attain the character of a true progressing menin- 
gitis. 



DISEASES OF THE RESPIRATORY TRACT. 295 

Typhoid fever beginning abruptly may cause confusion. 
The absence of leucocytosis and the later appearance of rose 
spots, the Widal reaction and enlarged spleen positively identi- 
fies it. 

Acute caseous pulmonary tuberculosis may set in with a 
chill and uniformly consolidate an entire pulmonary lobe 
within a remarkably short time. The temperature will run 
high and the entire clinical picture be identical with that of 
croupous pneumonia. Crisis does not occur, however, and 
eventually softening and break down of pulmonary tissue sets 
in. Elastic fibres and tubercle bacilli are to be detected in 
the sputum at this time, confirming the diagnosis. The 
most experienced are deceived, however, in the early stage of 
such a case. 

PLEUROPNEUMONIA. 

In a certain number of cases of pneumonia (6.8 per cent, 
in Holt's series of 398) pleurisy exists at the same time with 
the pneumonic process and to such an extent as to give the 
condition distinct clinical features. The pleural inflamma- 
tion is chiefly plastic in nature and the amount of serum 
poured out is relatively slight ; never to the extent seen 
in a primary pleurisy. At the autopsy we will find the 
pleural surfaces matted together and covered with a thick, 
yellow, plast'c exudate that can be readily scraped off and 
from the interstices of which turbid serum exudes. 

The surface of the entire lung on one side may be covered 
with this exudate even though only one lobe be consolidated. 
The changes in the lung are not necessarily lobar ; indeed, 
the broncho-pneumonic type of lesions is more frequently 
associated than purely croupous inflammation. 

If the disease has a chance to progress it terminates in em- 
pyema and as a rule, owing to the adhesions that develop, 
sacculated empyema results. 

The majority of cases prove fatal at the height of the dis- 
ease. In the first stage there is every evidence of an on-com- 



296 DISEASES OF CHILDREN. 

ing pneumonia, together with severe pain in the side and the 
physical signs of pleurisy. Friction sounds are plainly heard 
and in the course of a few days distinct dulness, bronchial 
breathing and broncophony can be detected. These latter 
signs are somewhat obscured by the thick fibrinous layer, but 
never to the extent that an effusion would produce. Aspira- 
tion is negative, as a rule. An exact diagnosis is at times 
impossible, but the symptoms are too severe for a simple 
pleurisy and too indistinct for a pure pneumonia. When 
effusion develops, in left sided cases, the heart becomes dis- 
placed. Extension of the line of dulness beyond the mid- 
sternal line is also strong evidence of pleural effusion. 

The prognosis is unfavorable as the pathological findings 
would naturally indicate. The younger the child, the worse 
the prognosis. Pericarditis is a common complication. Cases 
that survive must go through the course of an empyema 
with possibly severe crippling of the lung. When the pro- 
cess remains localized and abates in time, perfect recovery, 
barring some adhesions, is possible. 

Treatment. — The treatment of croupous pneumonia is es- 
sentially the same as that recommended for broncho-pneu- 
monia. Nevertheless there are certain remedies which are 
especially related to croupous exudations, in contradistinction 
to those of a purely catarrhal type, and they will, therefore, 
be called for here. Thus, Ipecac and Tartar emetic are less 
frequently indicated than Bryonia and Sulphur. In the early 
stages Aconite is by far the most useful drug. 

Iodine is recommended by Kafka {Homoeopatische Therapie) 
as being truly homoeopathic to the croupous exudation, as 
well as to most of the symptoms. The Iodide of Potash he 
considers more valuable in apex pneumonia, especially when 
there is a tuberculous tendency. 

The high fever and cerebral symptoms will call for Bella- 
donna or Veratrum viride. 

Tartar emetic and Bryonia hold the first place in pleuro- 
pneumonia. 



DISEASES OF THE RESPIRATORY TRACT. 297 

Although Phosphorus is more useful in broncho-pneumonia 
than in croupous pneumonia, still it is of the greatest service 
where there is marked congestion indicated by dyspnoea ; 
tightness across the upper portion of the chest; bloody ex- 
pectoration ; failing right heart and profound toxaemia. 

Sulphur is one of the most useful absorbents in the Materia 
Medica, being especially useful in the third stage of pneu- 
monia. It is recommended by Bidherr when exudation sets 
in, indicated by the appearance of the crepitant rale. 

Arsenicum is well suited to those atypical cases of severe 
grade, in which the poison of influenza is added to that of 
pneumonia. In the presence of abundant bronchial secretion 
with dyspnoea and cardiac weakness, the Iodide of Arsenic is 
preferable. 

Special symptoms are to be dealt with precisely as directed 
under Broncho-pneumonia. 

PULMONARY TUBERCULOSIS. 

Tuberculosis of the lungs during childhood manifests itself 
in a variety of forms, each depending upon the nature of the 
pathological findings for its clinical characteristics. Further- 
more, it may be a primary or a secondary condition, and as- 
sume either an acute or a chronic course. The different varie- 
ties are: i. Miliary Tuberculosis; 2. Caseous Pulmonary 
Tuberculosis ; 3. Fibro-Caseous, or Chronic Pulmonary Tuber- 
culosis. A fourth variety frequently encountered in adults 
namely, fibroid tuberculosis of the lungs, is so rare during 
childhood that it need not be considered specially. Tubercu- 
losis is separately discussed in the chapter on "Diathetic 
Diseases," to which the reader is referred for details regard- 
ing the factors concerned in the etiology of the disease as 
well as the bacteriology and pathology of the tuberculous in- 
fections. 

I. Miliary Tuberculosis. — Diffuse miliary tuberculosis of 
the lungs may occur primarily, in which case it runs the 
course of general tuberculosis described as the "pulmonary 
20 



298 DISEASES OF CHILDREN. 

type" (see article upon "Tuberculosis"). In these cases the 
bacillus gains entrance into the lungs either through the 
bronchial glands or by means of the general circulation. In 
the latter instance the infection arises from a local focus in 
some other portion of the body, e. g., a tuberculous joint af- 
fection. It may also be the terminal event of a chronic pul- 
monary tuberculosis, as a result of the discharge of the con- 
tents of a brokendown caseous mass into a bloodvessel, usu- 
ally a branch of the pulmonary vein (Weigert). The form 
arising from bronchial gland infection is the type encountered 
during infancy. It is hardly probable that pulmonary infec- 
tion through the lymphatic system from a primary tubercu- 
lous lesion in the intestines ever takes place. 

II. Caseous Pulmonary Tuberculosis, also described as 
acute and subacute pneumonic phthisis ("galloping consump- 
tion "), is the form of pulmonary tuberculosis belonging to 
the period of childhood, in contradistinction to the infantile 
form described above. It is much moie common than the 
chronic form, which, indeed, is rare in young children. Fre- 
quently it is engrafted upon a broncho-pneumonia, or occurs 
as a sequel to measles, whooping-cough or influenza. As a 
predisposing factor the tuberculous diathesis plays a most im- 
portant role, no doubt more so than during infancy, when ex- 
posure to infection, either atmospheric or through the food, 
is liable to result in the development of the disease even in a 
healthy babe. Any illness capable of undermining the health 
and lowering the child's resisting power will also predispose 
to tuberculosis, even in the absence of a tuberculous family 
history. 

The pathological changes in the lungs are either a diffuse 
pneumonic process which represents the lobar type and is 
rare, or a disseminated process representing the broncho- 
pneumonic type. This is the one usually encountered. We 
find isolated areas of consolidation, generally in the apical 
region, but not so strictlv confined here as in adults. Usually 
both lungs are affected throughout, the bases sharing in the 



DISEASES OF THE RESPIRATORY TRACT. 299 

pathological process. The consolidation is the result of the 
epithelial infiltration of the alveoli {desquamative pneumonia), 
and spreads from a terminal bronchus into the adjoining pul- 
monary parenchyma by contiguity of structure. Bronchitis 
and peri-bronchitis are associated with this process. The 
solid areas undergo caseation, which terminates in cavity for- 
mation if the case continue a sufficient length of time. Soft- 
ening and excavation are the result of secondarv infection 
with the streptococcus or staphylococcus (Prudden). The 
fever accompanying this process is one of' septic intoxication. 

Symptomatology. — Tuberculous pneumonia begins with 
high fever, as an ordinary broncho-pneumonia, together with 
the development of signs of infiltration of the lung structure. 
Physical examination demonstrates areas of consolidation, 
usually the apices and bases. The percussion note loses its 
resonance and assumes a tympanitic quality over these areas, 
while auscultation reveals loud, moist and sonorous rales, ac- 
companied by bronchial breathing. 

The temperature range is high and remitting in character. 
As softening of the pneumonic deposits sets in and the vital 
powers fail, the temperature may fall to subnormal in the 
early morning hours, lising above 102 in the evening. Pro- 
fuse sweating usually accompanies the fall in the temperature, 
and during the fever the skin is hot and dry and the cheeks 
flushed {hectic fever). 

The pulse is weak and rapid, varying from 140 to 160 beats. 
Breathing becomes rapid and labored, often rising to 60 respi- 
rations per minute during the acme of the fever. 

Cough remains troublesome throughout, at times being un- 
controllable. Emaciation and anaemia develop rapidly, the 
child becoming pale and haggard, its countenance wearing an 
expression of great distress. Expectoration is usually scanty 
in the beginning, but toward the end it may become profuse, 
changing from mucus to muco-pus. Hsemoptysis may occur. 
The expectoration contains Koch's bacillus, and frequentlv 
also fibres of connective tissue, beside pus corpuscles and epi- 
thelial debris. 



300 DISEASES OF CHILDREN. 

The course is rapid and fatal. Intermissions may occur, 
during which the disease remains quiescent for a short time, 
but it seldom fails to relight and terminate in a fatal issue. 
Instead of signs of resolution appearing at the end of a week 
or two, as in an ordinary broncho-pneumonia, or a crisis at 
the end of a week, as in a lobar pneumonia, the disease 
steadily progresses and the vital forces gradually fail. Death 
may occur within a period of two or three weeks from the be- 
ginning of the attack, or, owing to periods of temporary ces- 
sation of symptoms, be protracted beyond that time. A com- 
plete arrest of the process may take place, but it is seldom 
permanent, and, after several such remissions, the child suc- 
cumbs in a few months. In general it may be said, however, 
that the course is slower throughout than that of an ordinary 
broncho-pneumonia. 

Gastro-intestinal disturbances are present and hasten the 
decline. Diarrhoea is the most prominent of these. 

The circulation gradually fails, and respiratory embarrass- 
ment advances. The extremities are cold, and enlarged ca- 
pillaries may show prominently on the chest, even on the 
cheeks and hands, indicating pulmonary obstruction. A gen- 
eral oedema may set in toward the last, which usually disap- 
pears just prior to death. 

Infection of the abdominal viscera may occur as a compli- 
cation, especially if the case becomes protracted ; a tubercu- 
lous meningitis may arise in like manner. 

The prognosis is most unfavorable. It cannot be denied 
that occasionally, but very rarely, we encounter cases pre- 
senting every evidence of pneumonia of tuberculous origin 
that recover, or at least in which the disease is temporarily 
arrested. Even when evidence of a complicating meningitis 
is present this may occur. Such a case is reported by 
Baginsky {Berlin. Klin. IVoc/iensc/ir., 1881, No. 20), and I 
have personally seen cases that apparently presented this 
complication get well ; but the prognosis must always be 
guarded. Fowler (Fowler and Goodlee ''Diseases of the 



DISEASES OF THE RESPIRATORY TRACT. 301 

Lungs,") expresses himself on this topic as follows: u The 
prognosis is in all cases unfavorable, but not so grave in the 
broncho-pneumonic as in the lobar form. In the less acute 
cases it may fairly be hoped that the disease pass into a sub- 
acute or chronic form." 

Diagnosis. — A broncho-pneumonia in a child running a 
protracted course, giving no evidences of resolution, but 
rather those of destruction of lung-tissue, with hectic fever, 
should always arouse suspicion of tuberculosis. Likewise a 
lobar pneumonia running on without a crisis, but going into 
the above state, providing empyema be excluded, is of grave 
significance. This form, however, is rare, although I believe 
extensive consolidations are more commonly encountered in 
children than in adults. A clear family history of tubercu- 
losis and the tuberculous diathesis, or a history of prolonged 
exposure to a tuberculous source of infection, offer strong 
presumptive evidence. 

Positive evidence is offered by finding the bacillus of Koch 
in the sputum, with possibly fibres of elastic tissue. This di- 
agnostic sign is, however, not always available, owing to the 
difficulty of obtaining sputum. An ingenious and most satis- 
factory method of obtaining the sputum for microscopic ex- 
amination is carried out at Prof. L. Kmmett Holt's clinics. 
A catheter or small stomach tube is inserted several inches 
into the oesophagus after a coughing spell, by means of 
which sufficient sputum can be obtained, as children in- 
variably swallow their expectoration. This is a simple 
and perfectly reliable procedure and one that should never 
be neglected in suspicious cases. I am in the habit of attach- 
ing a glass syringe to the free end of the catheter for the pur- 
pose of aspirating enough expectoration for a satisfactory 
examination. 

The character of the fever is in itself a strong evidence of 
the nature of the disease, and when taken in conjunction with 
the rapid emaciation and prostration, anaemia, diarrhoea, and 
sweats, the case becomes quite clear. 



302 DISEASES OF CHILDREN. 

From this it will be seen that an ordinary broncho-pneu- 
monia should not be confused with caseous pulmonary tuber- 
culosis. A. diffuse broncho-pneumonia attended by acute dila- 
tation of the bronchi, however, may give rise to physical signs 
indistinguishable, for a time, from disseminated caseous tuber- 
culosis, and we should therefore be cautious in giving a posi- 
tive opinion (FowxER). 

The physical signs are those of either a disseminated bron- 
cho-pneumonia or of a lobar pneumonia. In the former, scat- 
tered areas of dulness, the note assuming a tympanitic quality, 
can be demonstrated, especially at the apices and the bases of 
the lungs, bilaterally distributed. The signs of bronchitis 
will be added, i. e., large and small moist rales. The rales 
are at first bubbling in character, later assuming a crackling 
sound. Over the consolidated areas bronchial breathing may 
be elicited, rarely typical tubular breathing. Signs are not 
well marked, as a rule, on account of the large amount of 
secretion which clogs up the bronchi. In the early stages of 
pulmonary tuberculosis, physical signs may be characteristi- 
cally scant and the fever be entirely disproportionate to the 
lesions demonstrable. Often the first signs are subcrepitant 
rales heard anteriorly in the mammary region, indicating in- 
vasion of the pulmonary parenchyma from the root of the 
lungs. (Holt). 

In the lobar form all the evidences of consolidation of an 
extensive area of lung-tissue will be found. 

The treatment is that of pneumonia. When the fever runs 
high, cold sponge-baths every two to three hours are of de- 
cided benefit. Food should be given at regular intervals, and 
in the form of liquids or semi-solids of the highest nutritive 
value. Milk, eggnog, broths into which a raw egg has been 
stirred, or strained vegetable broth and raw-meat juice are 
most suitable. Alcoholic stimulation cannot be dispensed 
with ; the average quantity will be about two drachms every 3 
hours during periods of adynamia. It not only sustains the 
strength of the patient, but possesses some food value, and 
assists in controlling the cough. 



DISEASES OF THE RESPIRATORY TRACT. 303 

A warm, moist atmosphere is to be maintained, together 
with the most thorough ventilation. The spraying of hydro- 
gen dioxid about the room is advantageous. When the 
cough becomes tight and suffocative in character, a cold pack 
about the chest is of great benefit. 

Remedies may be divided into two classes, namely, those 
calculated to affect the tuberculous process directly and those 
useful for special symptoms, such as cough, pyrexia, etc. To 
the first class belong notably the Iodides, especially the Iodide 
of Arsenic, and Iodoform, Calc. carb. and phos., Sulphur, 
Tuberciilinum. Kreosote is much used for its antiseptic ac- 
tion, but may do harm by upsetting the stomach. Remedies 
of the second class are Chininum arsenicosum and Baptisia 
for the pyrexia ; Silicea and Hyoscyamus for the profuse 
sweats ; Apomorphia, Tartar emetic, Hyoscyamus, Phosphorus 
and Lycopodium for the respiratory symptoms. 

Some of these remedies combine, so to speak, both offices — 
for example, the Iodide of Arsenic. It is not only a constitu- 
tional remedy, but at the same time exerts a potent influence 
over the pyrexia and the catarrhal symptoms. Likewise, one 
of the Calcareas may fulfill every requirement if decided con- 
stitutional indications are present, the Carbonate suiting the 
fat, pot-bellied, scrofulous child best; while a poorly-devel- 
oped, backward child, with flabby abdomen, lax joints and 
weak limbs, adenoid vegetations and enlarged tonsils, is more 
benefited by the Phosphate. 

Avian tuberculin is recommended by Cartier for broncho- 
pneumonia following one of the infectious fevers and assum- 
ing a "suspicious" type. The cough is incessant and tickling 
in character, the pulmonary symptoms become localized, ema- 
ciation sets in, and tuberculosis may be anticipated. 

II T. Fibro-Caseous or Chronic Pulmonary Tuberculosis. — 
The chronic form of pulmonary tuberculosis, in which fibrosis 
is added to the caseous process, is seldom encountered before 
the sixth year, not becoming a common disease until the time 
of puberty. Xo doubt most children showing a decided pre- 



304 DISEASES OF CHILDREN. 

disposition to tuberculosis succumb to either the acute pul- 
monary form or to general tuberculosis before this period. Its 
course is identical with that of cases of consumption in young 
adults, in children above six years. Under this age it may 
be less typical, the regular hectic fever so characteristic in 
adults and the classical night-sweats being absent. Indeed, 
extensive destruction of pulmonary tissue may take place in 
association with a moderately high temperature without 
marked remissions or sweating. 

A variety of lesions is found, the characteristic and most 
constant changes being caseation and fibrosis in conjunction 
with cavity formation. Owing to the tendency to destruction 
and excavation of pulmonary tissue, the term "ulcerative 
phthisis " is often applied to this disease. The coexistence of 
miliary granulations and areas of caseation and fibrosis indi- 
cates that the course has been marked by remissions, as well as 
periods during which the pathological process has been active. 
Such a period of activity often occurs immediately before the 
death of the patient, and during its continuance miliary tuber- 
cles in great number may form in parts of the lungs hitherto 
unaffected (Fowler). 

The seat of the primary lesion is one of the apices, and in 
the majority of cases the right. The process does not begin 
at the extreme apex of the lung, but about an inch below that 
point, and nearer the posterior and external than the anterior 
border, spreading thence backwards. The upper and posterior 
part of the lower lobe is involved often long before extensive 
infiltration or destruction of the upper lobe has taken place, 
and, as a rule, before the apex of the opposite lung is attacked. 
Infiltration of the lung at this site, together with infiltration 
of the apex, is almost positive proof of the existence of tuber- 
culous disease of the lungs (Fowler). 

Associated lesions usually found are bronchitis, peri- bron- 
chitis and bronchiectasis; emphysema (compensatory); pul- 
monary collapse, the result of bronchial obstruction ; cedema 
and congestion at the bases; pleurisy, usually chronic fibrous, 



DISEASES OF THE RESPIRATORY TRACT. 305 

although acute pleurisy with exudation is by no means an 
infrequent complication of phthisis. Lesions in other organs 
that may be encountered are tuberculous ulceration of the in- 
testines, amyloid disease of the internal organs, tuberculous 
adenitis, meningitis and tuberculous arthritis. 

Females seem more prone to consumption than males. The 
ages between twenty and thirty furnish the highest percen- 
tage of cases, the number gradually increasing from the fifth 
year to that time. 

Certain previous diseases invite it. An attack of acute 
pleurisy often precedes the outbreak of pulmonary tubercu- 
losis, or a lung impaired by a former pleurisy may become 
susceptible. Bronchitis may pave the way, but, according to 
Fowler, its importance is over-estimated. The same holds 
good for pneumonia. 

Valvular disease of the heart bears an important relation 
to pulmonary tuberculosis. Congenital stenosis of the pul- 
monary orifice offers a strong predisposition. Mitral stenosis 
is not uncommonly found associated with consumption, an 
observation to which I can add my testimony. The antago- 
nism between mitral disease, particularly regurgitation, and 
consumption, taught by Louis, is not absolute. Fowler has 
observed a number of cases in which the diseases co-existed, 
and others also have collected a sufficient number to disprove 
the theory. 

Syphilis may predispose to tuberculosis by lowering the 
resisting power of the organism. It is even claimed, by 
Hochsinger, that both the virus of syphilis and tuberculosis 
may be transmitted to the offspring by the parent at the same 
time. 

Symptomatology. — The only evidence of the disease to 
attract attention in the beginning may be emaciation, with 
gradually failing health. Cough is usually slight, and of a 
dry, hacking character, or there may be an associated bron- 
chitis, with free expectoration. In some cases, recurring at- 
tacks of acute bronchitis precede the pulmonary involvement; 



306 



DISEASES OF CHILDREN. 



in others, infiltration of the lungs advances steadily in the 
absence of all catarrhal manifestations. 

Hemoptysis may be the first symptom to arouse suspicion. 
Even in young children it is frequently observed (Baginsky), 
usually auguring a rapid course. Haemoptysis does not, how- 
ever, always indicate destruction of pulmonary tissue ; to the 
contrary, it is usually an early symptom, resulting from ob- 







fig. 39. — advanced case of fibro-caseous pulmonary 
tuberculosis in a boy ten years old. note 
emaciation; paralytic chest; flatten- 
ing of infra-clavicular spaces; 
also adenoid facies. 



struction of some of the smaller blood-vessels by the tubercu- 
lous infiltration with resulting engorgement and rupture of 
the collateral vessels. Chest pains are due to either localized 
persistent. 

Physical examination reveals an emaciated frame ; long, 
flat chest, and superficial, feeble respiratory movement in 



DISEASES OF THE RESPIRATORY TRACT. 307 

typical cases. The absence of the true paralytic thorax does 
not, however, exclude the possibility of pulmonary disease. 
When the process is active, the skin is dry and feverish. 
Commonly, enlarged superficial lymphatic glands can be felt 
in various regions of the body. The clavicle stands out 
prominently, as do also the angles of the scapulae, and the 
infra-scapular region is flattened. Palpation reveals in- 
creased vocal fremitus in either one or both infra-clavicular 
regions ; the percussion note is dull in the supra-clavicular 
region, and the area of dullness often extends down as far as 
the third rib anteriorly, occupying the interscapular space 
on one or both sides of the spinal column posteriorly. 
The dulness may be associated with a suggestion of tympan- 
itic quality. Auscultation reveals, in the early stages, harsh 
breathing in the affected apex, associated with fine, crackling 
rales. Broncho-vesicular breathing soon develops. As infil- 
tration advances, bronchial breathing can be elicited in the 
infra-clavicular space. The first place this can usually be 
demonstrated posteriorly is at a point opposite the fifth dorsal 
spine, midway between the border of the scapula and the 
spinous processes of the vertebrae (Fowler). As softening 
and excavation occur, the signs of cavity are added. 

Fever is an indication of the activity of the process. When 
not exceeding 100.4 F. it may be considered purely of tuber- 
culous origin; when higher, it is due to secondary infection, 
and usually betrays its septic character by marked remissions 
(Koch). While this is true in adults, it does not hold good 
in young children in whom the fever always tends to run 
high. Periods of latency may occur, during which there 
is no pyrexia, although the pulse, as a rule, is weak and rapid 
throughout the entire course of the disease. As characteristic 
of the tuberculous pulse, it is claimed that the number of 
beats per minute is not influenced by reclining or standing, 
as occurs normally. 

The morning temperature is frequently subnormal, even 
during periods of quiescence. With infiltration and begin- 



308 DISEASES OF CHILDREN. 

ning softening, the evening temperature rises to ioo° to 
100.5 F. Secondary infection and rapid disintegration of 
lung-tissue are accompanied by a higher evening rise, the 
fever assuming the hectic type. At times, extreme fluctua- 
tions in temperature occur without causing much distress to 
the patient. Fowler is of the opinion that high fever may 
be present without septic infection, simply indicating a rapid 
progress of the disease in an organism still capable of reac- 
tion. This, however, is at variance with the teaching of 
Koch and Prudden. Paroxysms of high fever, followed by 
sweating, invariably indicate an admixture of septic intoxi- 
cation. Night-sweats are a common and most distressing 
symptom ; ordinarily they simply indicate exhaustion, occur- 
ring as the temperature falls to normal or subnormal. 

The alimentary tract becomes deranged, and anorexia and 
diarrhoea are common complications. The latter symptom, 
occurring at the termination of the disease, indicates intes- 
tinal ulceration. Vomiting may be a troublesome symptom, 
resulting either from severe coughing paroxysms or gastritis. 

Albuminuria is more common in children than in adults 
(Baginsky). 

In rapidly progressing cases a distressing cough, with free 
expectoration of yellowish, lumpy muco-pus containing the 
bacillus in large numbers, will be found. Haemoptysis is 
generally associated with such cases. 

Chronic fibroid phthisis may be encountered in children, 
but it is rarer than the above variety. In these cases there is 
usually a dry, harassing cough and less pyrexia, while, patho- 
logically, fibrosis is in excess of the infiltrative process. The 
course is slower than that of fibro-caseous tuberculosis, but in 
the majority of cases an acute tuberculous complication brings 
on a fatal termination (Baginsky). 

The prognosis is unfavorable, especially when the disease 
develops at the period of puberty — a time when the organism 
requires every spark of vitality for its growth and develop- 
ment, and at which there is the strain of school life to be 









DISEASES OF THE RESPIRATORY TRACT. 309 

considered, In girls, the tendency to chlorosis is also an un- 
favorable event. In younger children, if the course be not 
an acute one, the prognosis is more favorable, but still grave. 
Cases have no doubt been checked, but it is impossible to 
foretell a relapse or a later complication, such as meningitis, 
setting in. If arrest in the stage of infiltration can be accom- 
plished, the prognosis is favorable. The constitution and 
family history must also be taken into consideration in form- 
ing an opinion as to prognosis. As Duckworth puts it, we 
do not cure our tuberculous patients ; all that we can do is to 
place them under conditions favoring an arrest of the process. 
A positive diagnosis is based upon a demonstration of the 
physical signs of infiltration and destruction of lung-tissue 
described above, the character of the fever, and the finding 
of the bacillus of Koch. A combination of any two of these 
data affords the strongest presumptive evidence of the exist- 
ence of phthisis. Early in the disease, however, at which 
time it is most important that the malady be recognized, it is 
not always possible to find unmistakable evidence of tubercu- 
losis ; and especially in children are we at a great disadvan- 
tage, owing to the difficulty of obtaining sputum for micro- 
scopical examination. If the child cannot be made to expec- 
torate into a cup, the stomach-tube should be passed as 
directed above (p. 301). Cough and emaciation in a child 
with a tuberculous family history, or with the history of hav- 
ing been exposed to such infection, together with slight 
evening pyrexia, are sufficient data to warrant a most thor- 
ough examination of the chest. The finding of a few local- 
ized subcrepitant rales at the apex of the lung, together with 
a prolonged expiratory sound in such a case, will enable us 
to make a diagnosis of beginning pulmonary tuberculosis. 
Later, as the classical symptoms of the disease develop, the 
diagnosis is comparatively easy. Chronic piimlent bronchitis 
is, perhaps, the most frequent condition we are called upon 
to differentiate ; but here the absence of the bacillus and the 
negative condition of the lungs will exclude tuberculosis. 



310 DISEASES OF CHILDREN. 

Treatment. — In the treatment, prophylaxis is of first im- 
portance. Children presenting a tuberculous family history 
are liable to succumb to pulmonary tuberculosis on account 
of an inherited constitutional weakness. This predisposition 
is not, however, confined to such alone, as any constitutional 
enfeeblement in which the resistance of the organism is sub- 
normal, especially when the chest is underdeveloped, offers a 
predisposing factor. Such children should be brought up in 
a locality where fresh air in abundance can be enjoyed, and 
they should be encouraged to lead an out-of-door life rather 
than be urged on in their studies. Particular stress should 
be laid on the physical development of the chest by suitable 
and methodically carried out breathing-exercises and calis- 
thenics ; and for overcoming the cold-catching tendency, a 
cold sponge-bath, followed by brisk rubbing with a coarse 
towel, is most efficacious. 

A careful inspection of the nose and throat should be insti- 
tuted early to determine the presence of local pathological 
conditions that may interfere with the proper performance of 
the function of respiration. The importance of early recog- 
nizing adenoid vegetations or enlarged tonsils, and promptly 
removing them by appropriate means, cannot be overesti- 
mated. And, lastly, it must be accepted as a fact beyond dis- 
pute that the most important prophylactic factor is the avoid- 
ance of giving entrance to the bacillus of Koch into the sys- 
tem. The infant's food should, therefore, be sterilized, unless 
it is positively known to be free from contamination. Nor 
must it be brought up in an environment menaced by the 
presence of a consumptive. The same holds good with older 
children. Until more rigorous sanitary measures are enforced 
and the consumptive is educated to dispose of his expectora- 
tion in a safe manner and avoid too intimate relations with 
those about him, the disease will not decrease very materially. 

When the disease becomes established it behooves us to 
decide whether the patient is to be cared for at home or sent 
to a more suitable climate. It is worse than useless to send 



DISEASES OF THE RESPIRATORY TRACT. 311 

away a patient whose condition is an acute one, or in whose 
lungs advanced destructive changes have already occurred, 
and pronounced emaciation, fever and night-sweats exist. On 
the other hand, a timely change of climate has saved many a 
life, especially if the patient can pursue an outdoor life. The 
requirements of a suitable climate are pure, uncontaminated 
air, equable temperature, and a maximum amount of sunshine. 
High altitude is by no means necessary ; it best suits cases in 
which the disease is limited and there are no cavities. It may 
prove disadvantageous to some cases by bringing on dilatation 
of the air- vesicles on account of the ratified state of the air, 
thus making it impossible for the patient to return to a low 
region. Haemoptysis also contra-indicates a high altitude, 
and neurotic temperaments are aggravated thereby. A mod- 
erate altitude is preferable in most cases. The most suitable 
locations offering this natural advantage are the Adirondacks, 
the Southern pine regions, and the great plains bordering the 
Rocky Mountains. A location at sea-level seems better for 
chronic cases with emphysema, especially when there is nerv- 
ous irritability, insomnia and loss of appetite. It is also 
beneficial in septic pyrexias. Many consumptives do not 
mind cold weather; in fact, it benefits them. For such, Mt. 
Pocono, the Adirondacks and Denver, Col., are good locations. 
Others, again, especially those in whom there is considerable 
bronchitis, are required to . seek a warm, moist climate, 
especially in winter. Florida, the coast region of Southern 
California, and the Bermudas offer these advantages. The 
main feature of climatic treatment, however, is the outdoor 
life invited thereby. No other form of treatment has yet 
given the promising results obtained in the sanatoria in 
which open-air treatment is systemically carried out, com- 
bined with forced feeding, hydro-therapy and judicious 
exercise. 

When it is impossible to send the patient away from home, 
he should receive all the benefits of the open-air treatment. 
When he is able to be out, he should enjoy every hour of sun- 



312 DISEASES OF CHILDREN. 

shine available. If he is too weak to walk, or if there is fever, 
he should sit in the sun, well protected with sufficient cloth- 
ing and screened from draughts. In winter, as well as in 
summer, the windows of the sick-room should be kept open. 
During the night the sleeping-chamber must be kept thor- 
oughly ventilated, there being less harm in night air than in 
a stuffy atmosphere. 

The diet is very important. So long as the appetite re- 
mains good and diarrhoea is absent, the case should not be 
despaired of. A change of climate often brings about a 
restoration of appetite when that has been on the wane, and 
may in this way alone confer great benefit. It is important 
to feed the patient as much as he can take ; in fact, overfeed- 
ing has even proven beneficial in some instances. Osier has 
seen good results following Debove's method of introducing a 
mixture of milk, egg and finely-powdered meat into the stom- 
ach through a stomach-tube, three times daily, in cases in 
which gastric symptoms were distressing. Raw eggs are es- 
pecially adapted as a food for the tuberculous. Cod-liver oil 
is usually well borne by children, and is useful so long as it 
does not disturb the digestion. Even in the presence of py- 
rexia not above 100.4 F. we should not refrain from liberal 
feeding. Alcoholics are useful here, particularly when they 
tend to increase the appetite. Eggnog is a desirable form in 
which whisky can be administered. Raw meat is supposed 
to possess antitoxic properties, and can be administered as 
balls of chopped meat rolled in pulverized sugar, in which 
form children will usually take it readily. Personally, I con- 
sider it one of the most valuable foods for the tuberculous. 

Special Symptoms. — When there is continuous pyrexia, or 
high evening temperature, rest in bed is imperative. Spong- 
ing with tepid water to which alcohol has been added exerts 
a refreshing and tonic influence, besides being a safe means of 
reducing temperature. The so-called "antipyretics" are posi- 
tively harmful. Such remedies as China, Chininum arseni- 
cum, Baptisia and Ferrum phos. present special indications 



DISEASES OF THE RESPIRATORY TRACT. 313 

for their selection in the pyrexia of tuberculosis, and exert a 
most favorable influence over the same. Full indications will 
be given later on. 

Cough. — A cough which occurs in the morning and is ac- 
companied by expectoration is useful, and should not be 
checked. Expectoration is materially aided by giving the 
patient a cup of hot milk, to which a teaspoonful of rum has 
been added, in the morning on awaking. On the other hand, 
a cough that continues during the night, causing loss of sleep v 
must be controlled (Fowler). 

The old school employ Codein for this purpose; but we 
have among our remedies most efficient means for controlling 
the cough, with which we do not run the risk of drying up 
secretions or overcoming reflex irritability to a dangerous 
degree. I would especially mention Hepar sulph., 3X trit., as 
a most valuable remedy for the teasing night-cough of 
phthisis. Drosera is highly recommended by Hughes {Man- 
ual of Therapeutics) for cough depending upon increased re- 
flex excitability. Beside these, Hyoscyamus, Lachesis, Ipecac 
and Corallium rubrum should be studied. When profuse ex- 
pectoration is present Stibium iodide 2x (Goodno), Arseni- 
cum jod., Lycopodium, Stannum met. and Calc. carb. are the 
remedies most likely to prove useful. They must be care- 
fully differentiated in order to yield the best results. 

Hczmoptysis, when slight and associated with tightness 
across the chest and hoarseness, calls for Phosphorus. Hughes 
places Phosphorus foremost when the air-passages are much 
implicated in the morbid process. Geranium maculatum, 
tincture, has proven of great benefit in profuse bloody expec- 
toration. 

The inhalation of Kreosote, a few drops in a mixture of al- 
cohol and chloroform, is often efficient in allaying an irritat- 
ing cough and in improving the character of the expectora- 
tion when it becomes offensive. 

Night-sweats are often uncontrollable, and try the physi- 
cian's skill to the utmost. I cannot see the feasibility of 
21 



314 DISEASES OF CHILDREN. 

using extreme measures to check the same, as the sweating is 
only a sign of exhaustion when it occurs during sleep, or the 
natural termination of the febrile movement when it occurs 
at the decline of the fever. Our aim should be to build up 
the patient, and, if necessary, we may administer a stimulant 
at bedtime. When due to fever, a tepid or cold sponge-bath 
at bedtime is beneficial. China tincture is a good remedy in 
these cases owing to its tonic properties. Silicea, 6x trit., acts 
most satisfactorily when there is pulmonary disintegration. I 
have seen an Iron tonic gradually relieve the condition where 
the usual routine treatment had been used without suc- 
cess. Hughes recommends Iodine for nocturnal sweats. 
Phosphoric acid 3X will do a great deal for the debility result- 
ing from sweats, diarrhoea and bronchorrhoea. Jaborandi is 
homoeopathic to profuse sweating, and has given good results. 
Goodno recommends Agaricin ix, one grain at bedtime. 
A tropin is the standby of the old school. 

Diarrhoea, when due to catarrh of the bowels, can be con- 
trolled by restricting the diet to semi-solids and selecting the 
proper remedy. Phosphoric acid is the most important one. 
When there is tuberculous ulceration of the bowel, slight hope 
for improvement is offered. This is the form encountered 
as a terminal stage of the disease. Arsenic may benefit this 
condition and should be tried. 

Gastric disorders may result from overfeeding. The best 
evidence of this is the presence of undigested food-particles 
in the stools (Fowler). When there is purely a gastric in- 
competency, Nux vomica proves of great value. A catarrhal 
condition calls for such remedies as Pulsatilla, Hydrastis and 
Ipecac. Kreosote is indicated when there is vomiting of 
glairy mucus, usually in the morning. It is a favorite rem- 
edy of the old school to improve the digestive function, in- 
creasing the appetite and checking flatulency. 

Laryngeal symptoms supervening during the course of 
phthisis are mostly catarrhal in nature. Spongia is the chief 
remedy (Hughes). Tuberculous laryngitis (ulcerative) re- 
quires the attention of a specialist. 






DISEASES OF THE RESPIRATORY TRACT. 315 

The following list of remedies, with their clinical indica- 
tions, may be studied for a fuller knowledge of the therapeu- 
tics of phthisis : 

Aconite. — Pleuritic stitches, and blood-spitting after taking 
cold. Ferrum phos. is similar, but under this remedy there is 
less circulatory excitement, and anaemia and vasomotor dis- 
turbances are pronounced. 

Arsen. alb. — Dyspnoea from exertion; cough between i 
A. M. and 3 A. m. Fever-heat and chilliness intermixed. 
Restlessness and thirst for small quantities of water. There 
is prostration and emaciation ; anaemia and oedema of ankles ; 
terminal diarrhoea. Mostly indicated in the pneumonic type. 
Arsen. j'od., 3xtrit, freshly prepared is well suited to the Jibro- 
caseous form of the disease when there is profuse purulent ex- 
pectoration ; emaciation ; hectic fever and prostration. Stibium 
iodide, 2x trit, is highly recommended by Goodno in cases 
presenting profuse muco-purulent expectoration. Stannum 
iodide has profuse purulent expectoration easily raised, and 
of sweetish taste. It is more useful in chronic bronchitis. 

Baptisia. — Chill in forenoon or afternoon, followed by heat 
and perspiration ; general weakness and languor. Baptisia 
is one of the best remedies for the pyrexia of phthisis, and 
has been extensively used since it was first recommended by 
Dr. J. S. Mitchell. It is usually employed in the tincture and 
lower dilutions. 

Bryonia. — Cutting pleuritic pain when taking a deep 
breath or coughing. Dry, deep cough, the irritation starting 
from the epigastric region. 

Calc. carb. — " Pre-tubercular stage " in strumous subjects, 
the characteristic features being a form of indigestion asso- 
ciated with acid eructations and difficulty in assimilating fats 
(Hughes). Pale, rapidly-growing youths (Phos. acid) or 
scrofulous children are especially benefited by this remedy. 
In the later stages it is indicated by tendency to perspire on 
slightest exertion ; damp, cold feet ; shortness of breath on 
ascending stairs ; expectoration consisting of mucus with an 



316 DISEASES OF CHILDREN. 

admixture of pus which sinks in water, leaving the frothy 
mucus floating above. 

Carbo veg. — Flatulent dyspepsia and chronic hoarseness. 

China. — Septic fever, consisting of a chill, followed by 
high fever and sweat, usually occurring at regular intervals. 
Anorexia ; chronic diarrhoea. (Tincture and lower dilutions.) 

The Arseniate of quinine, 3X trit, is better indicated when 
the pyrexia is more irregular, especially if arsenic symptoms 
are present. 

Ferrum phos. — Fever in the early stages, before septic in- 
fection has set in. Haemoptysis in the early stages not de- 
pendent upon excavation of lung-structure. 

Hepar sulph., 3X trit., two grains every hour at night until 
cough is relieved. The cough is due to a persistent irritation 
in larynx, not relieved by free expectoration. It is excited 
by uncovering any part of the body, or by contact of body 
with cool bedclothes on first retiring. There is usually slight 
hoarseness, with rattling of mucus in larynx, but, as before 
stated, expectoration does not relieve the symptoms. ■ Drosera 
has a deep, spasmodic cough presenting this element of hyper- 
esthesia, but there is not the free secretion present in Hepar. 
Hyoscyamus has symptoms of cough worse on lying down at 
night ; dry, spasmodic and titillating in character. 

Iodine. — This remedy also presents characteristic cough 
symptoms. " Constant tickling in the windpipe and under 
the sternum, with expectoration of a transparent mticus, 
sometimes streaked with blood. Morbid hunger, even soon 
after a meal, and yet loss of flesh. Dark hair and eyes " (C. 
G. R.). 

Kali carb. — Sharp stitches in chest; cough worse 3 A. M.; 
puffiness of upper eyelids and swelling of ankles. 

Lachesis. — Cough during sleep without awaking the pa- 
tient ; chilliness, followed by fever, with great talkativeness ; 
sensation of suffocation ; fluttering of heart ; offensive stools. 

Lycop. — Expectoration of large quantities of pus after neg- 
lected pneumonia (C. G. R.). Cough day and night, the ex- 



DISEASES OF THE RESPIRATORY TRACT. 317 

pectoration tasting salty. Hectic fever, with circumscribed 
redness of cheeks, usually late in afternoon (four p. M. to 
eight P. M., aggravation of symptoms). During the fever we 
often observe automatic fan-like movements of the alse nasi, 
not due to dyspnoea, but sympathetic with the pulmonary 
disturbance. u It suits cases of a chronic and passive char- 
acter, and is, I think, especially useful when phthisis occurs 
in young men." (Hughes.) 

Nux vom. — Digestive derangements and aggravation of 
cough symptoms from overeating. Kreosotttm 2x is one of 
the best remedies for persistent vomiting in phthisis. 

Phosphorus. — Tormenting cough, often with hoarseness ; 
worse toward midnight ; tight and painful. There is tight- 
ness across upper portion of chest; inability to lie on left 
side. "Cough in the earlier stages of phthisis, with unusual 
implication of the air-passages in the morbid process." 
(Hughes). 

Phosphoric acid, acts restoratively w T hen the system has 
been drained by long-continued diarrhoea or persistent night- 
sweats. 

Sulphur. — Delayed resolution after pneumonia; chronic 
catarrhal deposits at apices, with a few moist rales. Neuras- 
thenic individuals. Weak, gene feeling at n A. M., with 
craving for food or a stimulant. Vasomotor disturbances. 

Iodoform, 3X trit. — Two one-grain tablets four times daily. 
It has given me most promising results in incipient cases of 
nbro-caseous pulmonary tuberculosis, and I use it in prefer- 
ence to the other iodides in the stage of infiltration. 

Tuberculin (Koch) has been successfully employed in bron- 
cho-pneumonia, and is considered by Arnulphy capable of 
stopping the progress of incipient cases of tuberculosis of the 
lungs in a large proportion of cases (Clinique, June, 1897). 
Avian tuberculin is recommended by Cartier for suspicious 
broncho-pneumonia. These nosodes have usually been given 
in the higher dilutions, either the 30th or 100th, although 
Mersch obtained his results from the 6th. 



318 DISEASES OF CHILDREN. 

EMPHYSEMA. 

Overdistension of the air-vesicles of areas of pulmonary 
tissue occurs as a complication of almost any of the acute 
affections of the respiratory tract, resulting from either an 
interference with the function of a considerable portion of 
the lungs (vicarious or inspiratory emphysema), or from an 
obstruction higher up in the tract, leading to dilatation and 
even rupture of air-vesicles during expiration, especially 
when this is performed in a forcible manner. The latter 
variety, or expiratory emphysema, is by far the most pro- 
nounced form in which this condition is met with acutely, 
occurring as a common complication of whooping-cough, 
croup, asthma and measles, especially in rachitic children or 
those of lax fibre. It has also resulted from forcible expir- 
atory efforts performed voluntarily, and from the inflation of 
the lungs of the new-born in cases of asphyxia. Chronic em- 
physema is occasionally seen in children as a result of chronic 
bronchitis and organic heart disease. 

Anatomically, emphysema is classified as vesicular or alveo- 
lar, and interstitial. In the latter form there is an escape of 
air into the connective- tissue stroma of the lungs, sometimes 
burrowing beneath the pleura and along the mediastinum 
into the subcutaneous tissue of the supra-clavicular spaces. 
Only then can it be distinguished clinically from the vesicu- 
lar form when it makes its appearance externally, in the 
above manner. 

The chronic form, or substantive emphysema, is defined by 
Delafield as a chronic interstitial inflammation of the lungs, 
in which the dilatation of the air-spaces is a secondary phe- 
nomenon. Accordingly, it is a condition whose etiology and 
pathology are analogous to that of chronic endocarditis, 
endarteritis and nephritis. 

In acute emphysema the upper lobes are principally af- 
fected, and most markedly in their anterior borders. In the 
chronic form both lungs are more or less affected in their en- 
tirety, but seldom to the great extent observed in adults. 






DISEASES OF THE RESPIRATORY TRACT. 319 

The symptoms of a compensatory emphysema are always 
obscured by the original disease. Hyper-resonance, bulging 
of the supra-clavicular space during the expulsive efforts of 
coughing, exaggerated vesicular murmur and dyspnoea are 
all suggestive. 

Chronic emphysema presents the typical barrel-chest ; fee- 
ble respiratory murmur with prolonged expiration ; dimin- 
ished area of cardiac dullness ; cyanosis, dyspnoea, cough and 
expectoration ; vesiculo-tympanitic percussion-note. It must 
be remembered, however, that none of these signs are as pro- 
nounced as in adults, and the younger the child, the less the 
aberration from the normal. 

In both instances treatment is to be directed to the primary 
disease. 

Such remedies as Arsenicum, Arsenicum iodide, Aurum 
mur., Ipecac, Lobelia and Grindelia will be required for the 
symptoms of the disease per se. Coca and Quebracho are 
lauded by Hale as the only remedies giving continuous relief. 

Constitutional remedies are valuable in rachitic children, 
notably the Calcareas, Silicea, Ferrum phos., Baryta carb. and 
iodide, Fluoric acid and Sulphur. 

PLEURISY AND EMPYEMA. 

Inflammation of the pleura is rarely seen as a primary dis- 
ease during childhood, but it is quite a common accompani- 
ment of pneumonia, especially of severe forms of broncho- 
pneumonia. Pleurisy without exudation may accompany 
pulmonary disturbances of all kinds, and the frequency with 
which adhesions and thickening of the pleural membranes are 
encountered in the general run of autopsies upon children 
points to the great prevalence of this condition. 

The exudative variety of pleurisy in children is almost in- 
variably an empyema, and occurs most frequently as a com- 
plication of pneumonia, or develops simultaneously with the 
pneumonic process, which is the case in the pleuro-pneumonia 
described by some authors as a separate clinical condition. 
(See page 294). 



320 • DISEASES OE CHILDREN. 

The acute infectious fevers are responsible for the develop- 
ment of some cases of pleurisy, and in older children a purely 
serous effusion may occur as a result of tuberculosis or the 
rheumatic (?) diathesis. 

The micro-organisms playing the most prominent role in 
the etiology of purulent pleurisy are the pneumococcus, the 
pyogenic micrococci and the bacillus tuberculosis. Pneumococ- 
cus pleurisy is the most frequent form. It may occur simul- 
taneously with a pneumonia, or, what is more frequently the 
case, secondarily to the pulmonary affection, sometimes ap- 
pearing several weeks later (Strauss). The exudate may be 
either sero-fibrinous or purulent. In the latter case the effu- 
sion is thick, creamy or greenish, and not clotted. The prog- 
nosis is better than in the other forms; the course is also 
milder. 

Streptococcus pleurisy is more common in adults. The 
prognosis is not so favorable as in the pneumococcus variety. 
The course is more prolonged and the fluid re-accumulates 
after expiration. 

Tuberculous pleurisy may occur primarily, that is, in the 
absence of pulmonary tuberculosis ; but in these cases tuber- 
culosis of the bronchial glands is generally present. The 
effusion is sero-fibrinous at first and gradually becomes puru- 
lent. The course is slow and unfavorable. 

Pathology. — In the early stages of a pleurisy the membrane 
appears injected and lustreless ; later, it becomes roughened 
and coated with a layer of fibrinous exudate. The extent of 
this process depends upon the severity of the attack, and it 
will vary from a delicate film of fibrin, coating only that por- 
tion of the pleura .directly covering the affected portion of 
lung in a pneumonia, to a general involvement of the entire 
pleural cavity, with a thick layer of inflammatory products 
plus an abundance of sero-pus. In these pronounced cases 
the pleura appears coated with a yellowish-green deposit of 
varying thickness ; the opposing surfaces may become adher- 
ent, forming pockets in which an abundance of pus is found. 



DISEASES OF THE RESPIRATORY TRACT. 321 

If serum is poured out freely during the first stage, adhesions 
do not occur, at least not to a very great extent. This fluid 
sodu becomes purulent from the free admixture of leucocytes. 

Symptomatology. — An attack of pleurisy may be ushered 
in with repeated chills, as in adults, or with convulsions, 
which are especially common in infants. A dry, hacking 
cough and sharp, sticking pains in the side are the natural 
accompaniments of the inflammatory process. When free 
exudation takes place the pain disappears, but with this a new 
series of symptoms develop. 

The pain is expressed by severe crying after each coughing 
paroxysm or when the child is moved ; there is also a ten- 
dency to lie upon the affected side, together with increased ab- 
dominal breathing. If the child be old enough to express its 
suffering, it may mislead us by referring the pain to the epi- 
gastric region. 

With the appearance of fluid, which is mostly of a purulent 
nature, dyspnoea develops, its severity depending upon the 
amount of fluid present. The cough may become more and 
more severe, owing to a complicating bronchitis. 

The fever is remitting in character, seldom very high, rarely 
running above 103 ° F. As the acute symptoms subside a 
slight afternoon rise may remain to indicate that the condi- 
tion has become chronic, as it is very rare for an empyema to 
recover spontaneously. Obscure cases of sacculated empyema 
running a high fever for several weeks are occasionally en- 
countered, and may prove very puzzling. Such a case, fluc- 
tuating between 98 and 106. 2° F., has been recently reported 
by Holt {Archives of Pediatrics, Jan., 1902). 

Cases of pleurisy, fully recovering within a short period of 
time, and without surgical treatment, have been either a dry 
pleurisy, a pleuro-pneumonia with scanty exudate, or a serous 
effusion into which no micro-organisms have gained en- 
trance. An empyema resulting from infection with the pneu- 
mococcus may recover spontaneously in the course of two or 
three weeks, but those of streptococcus or tuberculous origin 



322 



DISEASES OF CHILDREN. 



seldom recover without surgical interference. The last men- 
tioned is, indeed, rarely benefited by any form of treatment. 
When pleurisy develops secondarily to another disease, its 
course is not essentially different from the above ; thus, in a 
pneumonia there will be a post-critical rise in the temperature 
with all the attending symptoms of pleurisy and effusion, 
(Fig. 40). Sometimes, however, it is impossible to say just 
when the pleurisy has developed, the increasing dyspnoea, 
pain and cough indicating the addition of this serious com- 




Day*Du \ ? | ? | /Q | // | /Jj | /J | /? | /f\ /{, | /^ j // | /f\ >Qpj 



FIG. 40.— TEMPERATURE CHART FROM A CASE OF EMPYEMA 

DEVELOPING AFTER PNEUMONIA OF THE LEFT LOWER 

LOBE. A DRAINAGE TUBE WAS INSERTED AT iX) 

WITH RESULTING DECLINE IN THE FEVER. 

plication. This frequently occurs in broncho-pneumonia, and 
as both conditions are then practically inseparable, the term 
pleuro-pneumonia has been rightly applied here. 

The physical signs by which pleurisy is recognized in chil- 
dren are mainly those indicating the presence of fluid in the 
thoracic cavity, as the early signs, namely, the friction-sound 
and local tenderness, are not so readily elicited here as in 
adults. By observing the posture of the child, however, and 



DISEASES OF THE RESPIRATORY TRACT. 323 

the fact that coughing produces severe pain, we often suspect 
a case in its early stages and are enabled to verify the diag- 
nosis when the effusion appears. Conditions in which sutr 
crepitant rales are present are a frequent source of error, they 
being easily mistaken for friction-sounds during infancy. For 
this reason the diagnosis of pleurisy depends upon a correct 
interpretation of painful inspiration, painful cough, the char- 
acteristic onset and fever, and, still later, the demonstration of 
a pleuritic exudate. 

In the early stages of pleurisy fixation of the thorax from 
the pain is often observed in children, producing a voluntary 
scoliosis, as pointed out by Ziemssen. As a result of this ab- 
normal position, the ribs are brought closely together on the 
affected side and the percussion note becomes dull. Under 
these circumstances, therefore, dulness may be observed before 
exudation has actually set in. 

After exudation occurs the symptoms are more character- 
istic. If the amount of fluid be considerable, there will be a 
noticeable bulging of the chest on the affected side, together 
with diminished motion. When the fluid occupies the left 
pleural cavity the heart is displaced to the right ; when oc- 
cupying the right pleural cavity there is a downward dis- 
placement of the liver. The pleural fold is also displaced 
beyond the midsternal line. 

Vocal fremitus is absent over the site of the fluid, while 
the percussion-note is flat and there is increased resistance. 
These two signs are among the most important data in the 
diagnosis of effusion. Percussing with the flat hand directly 
over the site of the fluid gives a very good demonstration of 
the resistance present. Above the level of the fluid tympan- 
itic resonance is obtained when the lungs are not entirely de- 
prived of air. The line of flatness will change its direction 
with a change in the position of the patient, providing the 
fluid is not inclosed by inflammatory adhesions. 

In fresh cases bronchial breathing is very frequently heard 
above the line of dulness, which only gradually gives place 



324 DISEASES OF CHILDREN. 

to the entire disappearance of the respiratory murmur with 
the increase in the exudate, (Henoch, " Vorlesung uber 
Ktnderkrankh.") Rosenbach (NothnagePs Encyclopedia, 
1902) has not met with this peculiar type of breathing and 
he calls attention to the lack of specific signs in the pleurisies 
of children. The fact is, there are no constant signs. As 
large effusions are rare, the symptoms are less uniform than 
in adults. All authorities agree on the importance of the 
free use of the exploring needle. Even in moderately large 
effusions it is common to hear bronchial breathing and bron- 
cophony over the entire back on the affected side. Moist 
rales may also be present to cause confusion. 

In children under three years the fluid is usually purulent, 
and even until puberty this tendency prevails According to 
Baccelli a purulent exudate is less likely to transmit the 
whispered voice, but this is not always the case. Subcuta- 
neous oedema of the thorax on the affected side is not so com- 
monly present in children as in adolescents and adults to 
indicate the purulent nature of the exudate. A positive 
diagnosis cannot, however, be made without the use of the 
aspirating needle, which is perfectly safe when used under 
proper aseptic precautions. In old cases, where the pus is 
too thick to be drawn into the needle, even this method will 
lead to error unless the negative result is properly interpreted. 
In a serous exudate, the presence of chain cocci, staphylo- 
cocci, or the diplococcus pneumoniae, indicates that it will 
become purulent. — Koplik. Tuberculous pleurisy is recog- 
nized by finding the tubercle bacillus in the effusion and ac- 
cording to Dieulafoy by the exclusive presence of lymphocytes 
and red blood corpuscles. In the other forms of infectious 
pleurisy polynuclear and large mononuclear leucocytes pre- 
dominate. 

Diagnosis. — The early diagnosis of fluid in the chest is of 
the utmost importance, particularly as the recovery of the 
patient depends much upon the time when proper treatment 
has been instituted. Many difficulties may be encountered 






DISEASES OF THE RESPIRATORY TRACT. 325 

in deciding upon this point, especially as the effusion is not 
generally a large one and because it is usually secondary to 
pneumonia — metapneumonic pleurisy. The history is there- 
fore not as clear as in primary pleurisy. Again, owing to the 
strong tendency for the fluid to become encapsulated, it does 
not produce the characteristic physical signs expected of free 
fluid in the chest. The determination of the character of the 
fluid has been fully discussed above. 

The chief indications upon which the diagnosis can be 
made are absence of vocal fremitus; flat quality of the per- 
cussion-note and resistance ; bronchial breathing and bronco- 
phony over the entire affected side posteriorly and displace- 
ment of viscera. Koplik lays special stress upon displace- 
ment of the pleural fold. Normally these folds meet in the 
midsternal line and when there is considerable fluid in either 
side of the chest cavity dulness will be found to extend be- 
yond the median line over toward the well side. In smaller 
effusions auscultatory signs are not characteristic and may be 
misleading on account of the good conduction of sound in 
the child's chest. 

Empyema should always be suspected when the tempera- 
ture remains high for a period beyond two weeks in cases of 
pneumonia, especially when bronchial breathing can be heard 
over an entire side. 

Encapsulated fluid in unusual sites, such as the upper por- 
tion of the chest, is very difficult to differentiate from per- 
sistent broncho-pneumonia and abscess of the lung. In the 
latter condition percussion and auscultation give practically 
the same signs, but the presence of loud, coarse pleuritic fric- 
tion sounds are of importance as favoring the diagnosis of 
abscess (Holt, Archives of Pediatrics, Jan., 1904). 

Pericardial effusion must also be borne in mind as a pos- 
sible condition likely to be confused with sacculated empyema. 

Prognosis. — Serous effusions are usually absorbed readily, 
seldom persisting over three weeks. If however pus produc- 
ing micro-organisms gain entrance into the pleural cavity 



326 DISEASES OF CHILDREN. 

the prognosis is immediately altered. As stated above, an 
empyema due to the pneumococcus presents the most favor- 
able prognosis, although it may run a prolonged and tedious 
course, the usual period being from some weeks to two 
months (Strauss). This is the variety that may recover 
spontaneously, or after one or two aspirations. When the 
streptococcus is present the fluid tends to re-accumulate un- 
less open drainage be instituted. The tuberculous variety is 
the least favorable. Spontaneous evacuation through the 
chest wall (usually in the region of the fourth or fifth rib) or 
through the bronchial tubes, by perforation into the lung 
parenchyma, is a not infrequent termination of the pneumo- 
coccus variety. The other varieties, however, rarely evacuate 
themselves and do not tend to reabsorb. At times perfora- 
tion into the peritoneal cavity takes place with a fatal issue. 
The usual cause of death in an untreated empyema is the 
gradual exhaustion or amyloid degeneration accompanying 
prolonged suppuration. Tuberculosis is also liable to super- 
vene. 

When the fluid is removed early there is a fair chance for 
the compressed lung being restored to complete function ; 
on the other hand, if the condition has been one of long 
standing, dense bands of adhesions have generally been 
formed to such an extent as to allow of but a partial inflation 
of the lungs, resulting in permanent deformity of the chest 
and spine. 

Treatment. — Local treatment is of little avail in children, 
with the exception of the judicious use of hot applications 
and a flannel binder in the early and painful stage. Fluid 
which is present in considerable amount should be promptly 
evacuated if absorption is not progressing rapidly ; under no 
circumstances should accumulations of fluid be allowed to re- 
main in the chest for a period exceeding two weeks, unless 
decided improvement is noted daily. As the accumulations 
are almost invariably purulent in character, they are difficult 
to absorb. 



DISEASES OF THE RESPIRATORY TRACT. 327 

Sometimes a partial removal of the fluid by aspiration pro- 
duces sufficient relief of the intrapleural tension to excite the 
activity of the absorbents and lead to a complete recovery. 
By this method undoubted cases of empyema have been cured 
without open drainage. — (Goodno.) 

In cases of long standing, however, and in serous pleurisies 
of large effusion, displaying a tendency to rapid recurrence 
after aspiration and producing alarming pressure symptoms, 
open drainage is to be instituted. Simple incision, when 
practiced under the strictest antiseptic precautions, yields 
such prompt and lasting results that it has to a great extent 
superseded the operation for the resection of a rib. One of 
the advantages which this operation offers is the foregoing of 
the use of a general anaesthetic, the local use of Ethyl chlo- 
ride or Cocaine being all-sufficient. 

Parace?itesis of the thorax is accomplished with either an 
aspirator, such as the Dieulafoy or Potain aspirator, or by 
means of a small trocar. Before inserting the trocar an ex- 
ploratory puncture with a large size hypodermic needle should 
be made to locate the fluid. Negative results with the hypo- 
dermic needle do not, however, exclude the presence of 
fluid, as the puncture may not have been sufficiently deep, 
the pus may be too thick to flow, or the needle may become 
clogged with fibrin, preventing the entrance of the fluid. The 
usual site of puncture is the sixth or seventh intercostal space 
in the mid-axillary line or the seventh or eighth interspace 
posteriorly. The needle should not be inserted too close to 
the spine, and should be directed toward the upper border of 
the rib rather than to its lower, on account of the intercostal 
arteries. Koplik insists on puncturing at the site indicating 
fluid, as elicited by flatness and absence of vocal fremitus; 
when the empyema is localized this rule is absolutely essen- 
tial to follow. 

Having decided upon the best site for the puncture, the 
area is thoroughly cleansed and the trocar, previously steril- 
ized, is forced through the thoracic wall with a slight rotary 



328 DISEASES OF CHILDREN. 

movement. The thumb is firmly held at a distance of about 
one inch from the point and the trocar inserted to this 
depth if abundant fluid is present; the stylet is then with- 
drawn from the canula and the fluid allowed to flow into a 
pus basin. Care must be taken not to allow the fluid to run 
out too rapidly, as syncope may result therefrom. Coughing 
is excited by the operation, but this facilitates the expulsion 
of the fluid. As the child inspires it is well to place the fin- 
ger over the opening of the canula to prevent air entering the 
pleural cavity. Should this take place it will, how r ever, do 
no harm. 

Technique of Incision. — The child is laid on its well side 
and the arm of the affected side held up by an assistant, there- 
by exposing the lateral region of the chest to its full extent. 
Beginning first behind the mid-axillary line, an incision is 
made in the sixth or seventh intercostal space and carried for- 
ward for a distance of one and one-half inches. The skin 
should previously have been scrubbed with soap and water 
and subjected to the action of a wet 1-2,000 Bichloride dress- 
ing for one hour. Ethyl chloride is the only anaesthetic re- 
quired. 

After dividing the skin and intercostal muscles an artery 
forceps is plunged through the pleura and an opening made 
sufficiently large to receive a drainage tube. The drainage 
tube is introduced with a tissue forceps for a distance of about 
two inches and its free end transfixed with a sterilized safety- 
pin. After all of the pus has been evacuated a dressing of 
sterilized gauze covered with absorbent cotton is applied, 
which will have to be changed once or twice daily, according 
to the amount of exudation forming. The tube should be re- 
moved every one to two days and thoroughly cleansed ; as the 
case improves a smaller tube may be used until it is proper ta 
allow the wound to heal. Irrigation of the pleural cavity is 
seldom necessary and is associated with a certain amount of 
danger. When a good-sized drainage tube cannot be intro- 
duced equally good results may be obtained from two smaller 
ones placed side by side. 



DISEASES OF THE RESPIRATORY TRACT. 329 

Relapses may, however, occur on the removal of the drain- 
age tubes, if there be a virulent streptococcus infection, neces- 
sitating the resection of a rib ; and if the lung has become 
markedly crippled, leaving an open cavity in spite of com- 
plete recession of the affected side of the thorax, the operation 
of Estlander is to be considered. 

In the tuberculous variety the ordinary operation for em- 
pyema seldom accomplishes anything, owing to the rigidity 
of the chest-walls and the complete collapse of the lung. Re- 
accumuiation of fluid always occurs after aspiration, although 
more slowly than in a streptococcus infection. It may be 
said that, as a rule, non-interference is the best plan, unless 
the necessity be urgent (Fowler). 

Remedies. — Aconite, Arnica, Belladonna, Bryonia, Kali 
card., Rhus tox., Scilla and Tartar emetic will be found use- 
ful for the early symptoms, they having a special relation to 
the inflammatory stage. 

When exudation is abundant, Apis, Arsenicum, Cantharis, 
Kali hydrojod. and Sulphur are most frequently indicated. 

In purulent collections one of the constitutional remedies, 
prescribed upon the temperamental and diathetic peculiarities 
of the patient, will yield most gratifying results and greatly 
hasten the progress of the case. Ars., Ars. iod., Calc. card. 
and phos., Hepar, Iodium, Mercurius, Silicea and Sulphur 
stand prominently among these. 

Aeon. — Sharp, stitching pain in side ; high fever, restless- 
ness and chills ; after exposure to cold, dry winds or checked 
perspiration. 

Apis. — Pleuritic effusion ; scanty urine. 

Arnica. — Traumatic cases ; haemorrhagic effusion. 

Arsenicum. — Profuse serous effusion ; dyspnoea ; cachexia ; 
prostration ; empyema. The Iodide of Arsenic is well suited 
to tuberculous cases, as is also Iodoform. 

Asclcpiis tuberosa. — Sharp, stitching pains in the side; 
dry, hacking cough. Complicating pneumonia and tubercu- 
losis. 

22 



330 DISEASES OF CHILDREN. 

Bellad. — Cerebral symptoms ; complicating the infectious 
fevers or exanthemata. 

Bryonia. — Early stage of all pleurisies, and in dry pleurisy 
frequently to the end. Sulphur is needed in the latter cases 
to complete the cure. Sharp, stitching pains, aggravated by 
motion and deep breathing ; friction sounds and local tender- 
ness. 

Calc. c. — To absorb the pleuritic exudate. Scrofulous and 
rachitic diathesis. 

Canth. — Profuse serous exudation ; frequent cough ; dysp- 
noea ; palpitation ; profuse sweats ; great weakness ; tendency 
to syncope; scanty and albuminous urine. — (K. Faivre.) 

Colchicum. — Rheumatic diathesis; sour-smelling sweats; 
scanty, red, turbid urine, with abundant uric acid and some 
albumin. 

Hepar. — Purulent accumulations ; also dry, croupous ex- 
udate ; abscess of lungs ; hectic fever. " Hepar will often 
help to clear up the confirmed cases of purulent pleurisy 
where galloping consumption is apparently threatening." — 
(Fischer.) 

Kali carb. — Violent stitching pains, especially on left side, 
worse in early morning (after fresh adhesions have formed 
during sleep), accompanied by dry cough and palpitation of 
the heart. When Bryonia fails to give relief. 

Kali hydr. — Serous exudations. 

Mercurius. — Syphilitic or rheumatic diathesis; pains per- 
sisting after the fever subsides ; constant chilliness, with ten- 
dency to sweat ; gastro-intestinal catarrh ; perihepatitis. 
Merc. corr. is useful in pleuritic effusions accompanying 
parenchymatous nephritis. 

Phosphorus. — Complicating broncho-pneumonia. Pain in 
mid-sternal region and on both sides, especially when cough- 
ing. Also in empyema with Bright's disease ; hypertrophy 
of right heart ; amyloid changes. Hard, dry, distressing 
cough with hoarseness. 

Rhus fox. — Acute rheumatic cases, after exposure to wet 

t 



DISEASES OF THE RESPIRATORY TRACT. 331 

or after physical overexertion. General aching and prostra- 
tion ; typhoid state. 

Scilla. — Sharp stitching pains in side with broncho-pneu- 
monia ; prostration ; cardiac weakness. Cannot lie on left 
side. 

Sulphur. — Later stages of dry pleurisy and after the effu- 
sion makes its appearance in the exudative variety. Sulphur 
is a most valuable absorbent, and we are always obliged to 
come back to this remedy when others fail to improve the 
condition, or when clear indications for others are not present. 



CHAPTER XII. 

DISEASES OF THE HEART AND ITS MEMBRANES. 

The heart affections of childhood are both congenital and 
acquired. Congenital affections may be either the result of 
fcetal endocarditis or developmental defects and abnormali- 
ties. Acquired heart disease presents the same pathological 
phenomena observed in adult life, with, however, such clini- 
cal deviations from the adult type of a given disease as must 
necessarily result from the physiological peculiarities of the 
circulatory apparatus distinctive of child-life. Functional 
disorders are also encountered, but with greater rarity than 
in adult life, as the common causes for this train of symp- 
toms, viz., abuse of coffee, tea, tobacco and alcoholics, also 
neurasthenia and hysteria, are infrequently active at this age. 
Reflex irritation, however, is a frequent source of cardiac 
symptoms in the child, notably, gastro-intestinal irritation, 
helminthiasis and teething. 

The heart is relatively larger in infancy than in later life, 
but it does not increase in size proportionally with the growth 
of the child, developing only slightly during the first five 
years of childhood (Barthez and Rilliet). It occupies a higher 
and more horizontal position than in the adult, and for this 
reason cardiac dulness extends relatively further both to the 
right and to the left of the sternum. (Fig. 41.) Up to the sixth 
year dulness may extend beyond the right border of the sternum, 
and the apex is generally found outside of the left nipple- 
line up to the fourth year. Again, the apex may be in the 
fourth intercostal space until the sixth or seventh year. After 
the seventh year, however, it should be located well within 
the left nipple-line and in the fifth intercostal space, to indi- 
cate a perfectly normal condition. It is important to remem- 
ber that the nipple is not invariably a fixed point, as it may 



DISEASES OF THE HEART AND ITS MEMBRANES. 333 

be found in the third or fourth intercostal space or over the 
fourth rib. Most frequently it is situated over the fourth rib, 
somewhat nearer the median than to the mid-axillary line. 

Deep cardiac dulness extends beyond the left mammary 
line up to the second intercostal space, and on the right it 




FIG. 41— SKIAGRAPH OF CHILD'S CHKST, THRKK YKARS OIvD, 
POSTERIOR ASPECT, THK SHADED PORTIONS INDI- 
CATING THE HEART AND THE UVKR. 

may reach to or even beyond the parasternal line in young 
children. (Sahli, Topographische Percussion im Kinde Salter.) 
The same author has found this puerile type of heart as late 
as the twelfth year, although by the sixth year the rela- 



334 



DISEASES OF CHILDREN. 





FIG. 42. — CARDIAC DULNESS AT ONE 

YEAR, SIX YEARS AND 

TWELVE YEARS. 



tions as found in the adult 
are usually established. He 
further states that the area 
covered by the deep dulness 
differs in size and shape from 
the heart itself, owing to the 
projection of the borders of 
the heart upon a chest wall 
more convex than in the 
adult, and the admixture of a 
certain amount of "lateral 
dulness," resulting from the 
great resiliency of the chest 
wall. The heart is therefore 
not as large es the boundary 
obtained by deep percussion 
would indicate (Fig'. 42). 

Owing to the yielding 
character of the sternum and 
the costal cartilages, enlarge- 
ment of the heart may cause 
a decided bulging of the front 
of the thorax up to the third 
year. This is usually seen in 
congenital heart disease. The 
third piece of the sternum 
may be displaced at even a 
later period, as Rotch points 
out, owing to the fact that it 
is ossified later than the upper 
portions. Pericardial effusion 
will cause bulging over the 
heart at any period of child- 
hood. 

The distance of the apex 
from the mid-sternal line I 






DISEASES OF THE HEART AND ITS MEMBRANES. 335 

have found to be from 4.5 cm. to 5 cm. in the new-born. By 
the tenth year it is 7 cm. in the average case. In a male child 
from one to two years old it is from 5.5 to 6 cm., usually a 
trifle less in females. From the fourth to the sixth year it 
averages 6 to 6.5 cm. and may reach 7 cm. by the seventh 
year. The yearly gain in the distance of the apex from the 
median line seems trifling and does not appear to correspond 
with the increase in size of the heart, but it must be remem- 
bered that the heart is relatively large in early childhood and 
also that it assumes a more vertical position with the fuller 
development of the child. 

The pulse is soft and dicrotic in character during child- 
hood. It is rapid and arythmic in infants. Its rate is about 
130 at birth ; 120 at end of first year, and usually remains 
about 100 up the fifth year. 

The chilcPs heart exhibits a greater resistance to organic 
disease than the adult's. The explanation of this is, accord- 
ing to Soltman (" Der Kinderarzt," ix., No. 2, 1898), the ab- 
normal elasticity of the great vessels, the relatively greater 
muscular development of the heart, and the relation of the 
ventricles to one another. Intra-ventricular pressure has long 
been held to exert a pronounced influence in the development 
of endocarditis and its deformities, as shown by the over- 
whelming frequency with which it is found in the left heart 
after birth, and in the right during intra-uterine life. 

The blood pressure in the arteries is considerably lower in 
the child than in the adult, owing to the relatively greater de- 
velopment of the aorta and the low arterial tension. The nor- 
mal blood pressure in children up to the third year is about 
90 to 109 mm. of mercury with the Riva Rocci sphygmomano- 
meter while in adults it ranges from 125 to 135 mm. The 
volume of the heart compared with that of the aorta is al- 
most three times as great at puberty as it is in infancy. 

Normally the first sound heard at the apex is the loudest ; 
next comes the pulmonary second best heard in the second 
interspace at the margin of the sternum. The aortic second 






336 DISEASES OF CHILDREN. 

is heard best at the right border of the sternum, a little higher 
up. At puberty it is usually a trifle louder than the pulmo- 
nary second, although they may be of about the same in- 
tensity. It is wrong to speak of the pulmonary second sound 
being accentuated simply because it is louder than the aortic. 
As Cabot says, it must be distinctly louder than under normal 
circumstances in order to be of pathological significance. 

The characteristics of cardiac murmurs (excluding those 
due to congenital defects) are summarized by Soltman as fol- 
lows : 

AncBmic murmurs are rare in the first four years, and even 
up to the eighth year, but they are comparatively common at 
puberty, at which time anaemia and chlorosis are prevalent. 
The low blood-pressure in the ventricles and large source of 
origin of the great blood-vessels in early childhood explains 
their infrequency, their reverse condition obtaining at puberty. 
They are heard loudest at the pulmonary valve, and are sys- 
tolic. There must be no heaving impulse, accentuated second 
sound, or extension of the apex-beat beyond the mammillary 
line. The pulmonary area is so frequently the seat of mur- 
murs that Balfour has referred to it as the area of auscultatory 
romance. It is well always to bear this in mind before ventur- 
ing an opinion as to the existence of heart disease on so 
slender a basis. 

Cardio-pulmonary murmurs (Hochsinger) are produced by 
the transmission of the contractions of the heart and its move- 
ments to the lungs. These murmurs are also systolic, and 
are differentiated from anaemic murmurs by their definite re- 
lation to the respiratory function, being increased during 
forced and suspended by a cessation of respiration. They are 
common in children with deformed chests, due to rickets or 
Pott's disease, and are best heard over the praecordial region. 

Endocarditic systolic murmurs are heard in mitral insuffi- 
ciency ; and for a long time this sign, together with a heav- 
ing impulse, may be the only symptoms of endocarditis, 
cardiac enlargement, accentuated second sound and increased 
tension in the pulmonary artery being absent. 






DISEASES OF THE HEART AND ITS MEMBRANES. 337 

Other murmurs which may be heard in chronic valvular 
disease are the presystolic^ which may likewise be felt as a 
thrill running up into the cardiac systole. Occasionally a 
presystolic murmur may be heard where at the autopsy no 
mitral stenosis has existed, the valves simply being distorted 
or one of the chordae ruptured. Again, mitral stenosis is not 
always accompanied by the presystolic murmur, but in such 
cases the murmur can often be brought out by causing the 
patient to exert himself. On the whole, the presystolic is the 
most fugitive murmur encountered. 

The Flint murmur — a presystolic apical murmur heard in 
aortic insufficiency — is so rarely encountered in children that 
it need scarcely be considered. A diastolic mitral murmur may 
occur in old mitral cases where there is much dilatation with- 
out being indicative of aortic regurgitation. It is accom- 
panied by a loud, banging, pulmonary second sound, and is 
explained by Steell as resulting from high pressure in the 
pulmonary artery. As the aortic diastolic murmur is somer 
times heard at the apex, considerable confusion in diagnosis 
may arise, especially if we only take the murmur into consid- 
eration. The murmur Steell refers to should not be confused 
with the diastolic shock and reduplication heard in adher- 
ent pericardium. On account of the rapidity of the heart's 
action it is practically impossible to distinguish between a 
presystolic and a diastolic murmur. 

CONGENITAL DISEASES AND DEFORMITIES. 

As has been said above, congenital heart affections result 
from either foetal endocarditis or interrupted or abnormal de- 
velopment. Frequently, however, both of these processes act 
together — a mechanical obstruction in the circulation, as a re- 
sult of endocarditis, leading to non-closure of the auricular 
and ventricular septa or of the ductus arteriosus. For this rea- 
son it is more common to find a combination of defects rather 
than an uncomplicated lesion. Thus, Holt found, from an 
analysis of 242 cases, that the most frequent lesions were a 



338 DISEASES OF CHILDREN. 

combination of pulmonic stenosis with defective ventricular 
septum, pulmonic stenosis with defective auricular septum, 
the three lesions associated, or the first two with a patent 
ductus arteriosus. 

Foetal Endocarditis. — Inflammation of the endocardium in 
the foetus is of the chronic or sclerotic variety, verrucose en- 
docarditis being very rare (OSLER, Keating *s Cyclopes did). 
Small, nodular bodies, the remains of foetal structure (Ber- 
nays), and small, rounded, bead-like bodies of a deep purple 
color, which are the remains of a hsemorrhage (Osler), have 
frequently been mistaken as evidences of endocarditis, leading 
to a misconception as to the prevalence of this affection. The 
characteristics of foetal endocarditis are thickening of the 
segments of the valves, their edges becoming rounded and 
shrunken. The semilunar valves become obliterated, leaving 
a stiff, contracted ridge at the orifice of the great vessels. The 
right heart is most liable to endocarditis, as well as to errors 
of development. 

Congenital Anomalies. — Mentioned in the order of their 
frequency, according to Holt, congenital anomalies of the 
heart may be classified as follows : 

i. Defect in the Ventricular Septum. 

2. Defect in the Auricular Septum, or Patent Foramen 
Ovale. 

3. Pulmonic Stenosis, or Atresia. 

4. Patent Ductus Arteriosus. 

5. Abnormalities in the Origin of the Great Vessels. 

6. Pulmonic Insufficiency. 

7. Tricuspid Insufficiency. 

8. Tricuspid Stenosis, or Atresia. 

9. Mitral Insufficiency. 

10. Mitral Stenosis, or Atresia. 

11. Aortic Insufficiency. 

12. Aortic Stenosis, or Atresia. 

13. Transposition of the Heart. 

14. Ectocardia. 



DISEASES OF THE HEART AND ITS MEMBRANES. 339 

Defect of the ventricular septum is most frequently associ- 
ated with pulmonic stenosis or defect of the auricular septum. 
The defect is most frequently found in the anterior muscular 
portion of the septum (RokiTANsky). If compensatory hy- 
pertrophy of the right ventricle supervenes, no apparent 
symptoms may be present. Cyanosis results from an ob- 
structed venous circulation, with embarrassed respiration, cy- 
anosis and oedema. This, and not the mixing of arterial with 
venous blood, is the cause of the cyanosis (Baginsky). 

Patency of the foramen ovale may exist without any evi- 
dence of cardiac disease. When, however, other anomalies 
increasing the pressure in the right auricle co-exist, a mixing 
of venous and arterial blood takes place, with resulting cya- 
nosis. Under these circumstances the child is liable to an 
early death. 

Stenosis of the pitlmonary artery is one of the commonest 
of congenital heart affections, as a rule being responsible for 
the existence of the above-mentioned anomalies. The usual 
cause for the stenosis is endocarditis, although there may be 
a developmental defect of the pulmonary artery (ostium) or 
of the conus arteriosus. The symptoms depend upon the 
amount of constriction at the pulmonary orifice. The infant 
may die shortly after birth with intense cyanosis and as- 
phyxia, or it may grow up to adult life, with, however, signs 
of deficient aeration of the blood, cyanosis from undue phy- 
sical exertion, coldness of the extremities, clubbing of the 
finger-nails, and mental and physical apathy. Simple pul- 
monary stenosis is found only before the thirteenth month 
according to Rokitansky. The obstruction to the circulation 
in the great majority of cases that do not die in early infancy 
leads to the defects mentioned above. 

Patent ductus arteriosus does not necessarily produce symp- 
toms. Hirst finds a certain degree of patency of the duct 
quite common in children during the first year of life, but in 
these cases there is no appreciable deviation from the normal 
circulation. The symptoms produced are hypertrophy and 



340 DISEASES OF CHILDREN. 

dilatation of the right ventricle ; dilatation of the pulmonary 
artery ; dyspnoea and cyanosis; bronchitis. The physical 
signs are pronounced. 

Abnormalities in the origin of the great vessels are rare, and 
lead to early death or make extra-uterine life impossible, un- 
less there is an open foramen ovale or a communication be- 
tween the pulmonary veins and the right side of the heart. 

Tricuspid insufficiency and stenosis are grave defects, result- 
ing from endocarditis. There may be complete atresia of the 
orifice, in which case a degree of circulation is maintained 
through an incomplete ventricular septum. The right heart 
becomes dilated and hypertrophied ; there is cyanosis and 
tendency to venous haemorrhages. 

Affections of the left heart are rarer than those of the right, 
and result likewise from endocarditis. The symptoms and 
physical signs are the same as observed later in life. 

The symptoms of congenital heart affections may be summed 
up as the indications of deficient aeration of the blood or a 
mixing of venous with arterial blood, and interference in the 
systemic circulation. Cyanosis is the most persistent symp- 
tom, and is, in fact, pathognomonic of congenital heart dis- 
ease in the absence of other causes capable of exciting this 
phenomenon. Among these may be mentioned pneumonia, 
asphyxia, bronchitis, atelectasis, congenital pleurisy, partial 
occlusion of the trachea, degeneration of the blood, interfer- 
ence with the nerves of respiration. — (Hirst.) 

Dyspnoea is another prominent symptom. Among the 
later manifestations of congenital heart disease are clubbing 
of the finger-nails, cold extremities, mental and physical 
apathy, deformity of the chest from hypertrophy, and dilata- 
tion of the heart. Hypertrophy will produce deformity of 
the sternum up to the third year. 

The first symptoms are usually noticeable at birth, the 
child being a so-called " blue-baby." At other times they are 
very mild, and are only noticed when the child becomes ex- 
cited or attempts physical exertion. Again, the defect may 



DISEASES OF THE HEART AND ITS MEMBRANES. 341 

not be suspected until an acute affection of the respiratory 
tract precipitates the symptoms, or it may not become appa- 
rent until the child grows up. 

The diagnosis rests upon a recognition of the above-men- 
tioned symptoms, together with the physical signs. Accord- 
ing to Sansom, a patent foramen ovale is to be recognized by 
cyanosis without a heart murmur (in which case we must 
necessarily exclude all other causes for cyanosis), or by cya- 
nosis with systolic and presystolic murmurs over the carti- 
lages of the third and fourth ribs. The same observer also 
claims that defective ventricular septum is to be recognized by 
a loud systolic murmur over the praecordium and between 
the shoulders, not transmitted to the vessels. 

In tricuspid stenosis and insufficiency there is hypertrophy 
and dilatation of the right heart, labored heart's action, pre- 
cordial thrill, loud systolic and diastolic murmurs at the apex. 

Stenosis of the pulmonary artery presents a hypertrophied 
right heart ; loud systolic murmur over the second and third 
costal cartilages to the left of the sternum, not transmitted 
into the carotids, and precordial thrill. The pulmonary sec- 
ond sound is weakened. When these signs are present in a 
child over thirteen months old it can be taken for granted 
that there is an open foramen ovale. When the murmur is 
also transmitted into the carotids it points to associated sep- 
tum defect. When there is a loud, buzzing murmur trans- 
mitted into the carotids and subclavians, together with accen- 
tuated pulmonary second sound and hypertrophy of both ven- 
tricles, there is probably associated an open ductus arteriosus 
(HochsingER, Auscultation des Kindlichen Herzens). 

Patency of the ductus arteriosus leads to rapid hypertrophy 
of the right ventricle and dilatation of the pulmonary artery, 
increased area of cardiac dulness, long-continued systolic mur- 
mur with thrill and cold surface. The presence of a thrill and 
a distinctly-defined area of dulness in the second intercostal 
space to the left of the sternum, above the heart, is of great 
diagnostic import (Koplik, Diseases of Infancy and Child- 
hood). 



342 DISEASES OF CHILDREN. 

The treatment must aim at a betterment of the condition of 
the circulation through compensatory changes in the heart, 
and protection against external influences and physical over- 
exertion. Acute affections of the respiratory tract are espe- 
cially to be feared. Attacks of cyanosis or threatened cardiac 
failure and dyspnoea will call for stimulation with either aro- 
matic spirits of ammonia or brandy. 

On general lines Aconite, Arsenicum, Camphor, Cuprum, 
Digitalis, Glonoin, Lachesis, Rhus tox. and Veratrum viride 
are to be considered, their symptomatology covering the con- 
ditions met with in these cases, namely, hypertrophy, dysp- 
noea, excessive heart-action, cyanosis, etc. When symptoms 
are urgent spirits of ammonia will prove helpful. 

PERICARDITIS. 

Pericarditis in infancy is almost invariably seen as a com- 
plication of pneumonia, especially those severe pneumonias 
in which the pleura is notably involved (pleuro-pneumonia). 
Later on it will be seen secondary to rheumatism, pleurisy, 
scarlet fever and tuberculosis. Of all the causes capable of 
exciting pericarditis, rheumatism is the most important, and 
a certain amount of pericardial involvement is always to be 
suspected in severe cases of rheumatic endocarditis, although 
under these circumstances effusion seldom takes place. 

Traumatism and caries of the ribs or vertebrae are local 
causes which may excite a pericarditis. 

The effusion shows a strong tendency to become purulent, 
as do all effusions into serous membranes during childhood. 
The cases I have seen at autopsy, complicating pneumonia, 
were serous. Abundant fibrinous exudate is, as a rule, thrown 
out and a gluing together of the layers with complete oblitera- 
tion of the pericardial sac is the usual unfortunate result. 

The pathological changes noted elsewere in inflammations 
of serous membranes are to be seen in pericarditis. The 
tendency to the pouring out of effusion, containing cellular 
elements in abundance, is pronounced. The dry stage is of 



DISEASES OF THE HEART AND ITS MEMBRANES. 343 

short duration. When the amount of fibrin, which covers the 
serous surfaces, is considerable and the effusion not sufficient 
to separate the layers, the heart presents a shaggy, irregular 
surface. The opposing surfaces may become adherent with 
a net-work of villous bands. As these bands of fibrinous exu- 
date are absorbed tHey are replaced by granulation tissue rich 
in fibrinoblasts and permanent connective tissue formation 
results. More or less mediastinitis, as a rule, accompanies 
pericarditis in children. 

Adhesions form to a greater or less degree in all cases which 
recover from the acute symptoms. This leads to a hyper- 
trophy of the heart, or dilatation from interference with the 
nutrition of the myocardium. When absorption of the effu- 
sion is delayed, myocarditis develops, usually, leading to 
dilatation. 

Symptomatology. — The early symptoms of pericarditis are 
rarely recognized in an infant owing to their obscurity and 
overweighing symptoms of the disease to which it is sec- 
ondary. 

If the child is old enough to complain of pain in the region 
of the heart, which may also be referred to as radiating to the 
left shoulder or epigastrium, or as occurring alone. in these 
locations, a careful physical examination will reveal local 
tenderness and possibly cardiac friction-sounds, beside direct- 
ing our attention to the fixation of the left side of the thorax. 
If friction-sounds are elicited, they will be heard as a rubbing 
or crackling sound synchronous with the heart's action and in- 
dependent of respiration. They are most distinct under the 
fourth rib to the left of the sternum, and may simulate a 
mitral regurgitation murmur. However, cardiac friction- 
sounds do not only accompany the heart-sounds, but they are 
prolonged beyond them, being interposed and at times oc- 
cupying the whole duration of the cardiac action (Skoda). 
In several cases I have heard the friction-sound most dis- 
tinctly toward the base of the heart. Here it will persist 
even when moderate effusion has occurred, because this 
gravitates to the bottom of the pericardial sac. 



344 DISEASES OF CHILDREN. 

With the appearance of the effusion the pulse, which was 
at first full and irritated, becomes feeble and irregular. Op- 
pression, dyspnoea and cyanosis develop with the outpouring 
of sufficient fluid to embarrass the heart's action ; and event- 
ually convulsions, and in older children delirium and coma, 
close the scene in fatal cases. A rapid outpouring of serum 
into the pericardium may produce sudden death. We some- 
times see this occur during an attack of rheumatic fever and 
in pneumonia. 

The pulse is of the greatest importance in recognizing 
acute inflammatory affections of the heart, being strongly 
suggestive of such a complication when irregularity and en- 
feeblement suddenly develop during an acute illness. The 
pulsus paradoxus may be present, but is not pathognomonic, 
as it may occur under other conditions in childhood (Stef- 
FEn). Bulging of the prsecordial region, increased area of 
cardiac dulness, and muffling of the heart-sounds and im- 
pulse are only to be elicited in severe cases. The two last 
signs are notably difficult to determine on account of the 
natural resiliency of the child's thorax and the greater ac- 
commodation possible under reverse conditions. The area of 
dulness is not triangular as in adults, and the heart, with its 
distended sack, retains its normal position, simply enlarging. 
Enlargement is more pronounced to the left. Unless dulness 
reaches up to the second interspace on the right side, it is 
more likely due to dilatation of the right ventricle than to 
fluid (Koplik). The percussion note is flat and resistent. 

Adhesions are to be suspected when there is a displacement 
of the apex not due to marked hypertrophy, or cardiac dila- 
tation and retraction of the intercostal space during systole. 
The mere retraction of the apex region during systole is by 
no means diagnostic of pericardial adhesions. When, how- 
ever, associated with retraction of a considerable area of the 
thorax during systole, which rapidly returns to normal dur- 
ing diastole, we have strong evidence of the same (Gerhardt, 
Lehrbuch der Auskultation u. Percussion). Perhaps the most 






DISEASES OF THE HEART AND ITS MEMBRANES. 345 

conclusive sign is that pointed out by Broadbent, namely, re- 
traction of the lower intercostal spaces posteriorly, due to 
tugging on the adherent diaphragm. The sudden rebound 
after systole produces a diastolic shock which is also pathog- 
nomonic taken in conjunction with the above signs. This is 
followed by a sudden collapse of the veins of the neck 
(Friedreich). When thickening and contraction of the 
mediastinal structures, especially in the area surrounding the 
upper portion of the pericardium, is associated, there may be 
lessening of the calibre of the radial pulses and swelling of 
the neck veins during inspiration (Kussmaul). In many 
cases the diagnosis can be made as nearly as any physical 
signs permit by the following brief observations insisted on 
by Paul {Diseases of the Heart) — cardiac hypertrophy ; violent 
impulse of the heart, as a whole, but a feeble impulse of the 
apex. To this should be added, diastolic shock. 

The prognosis of pericarditis is always grave, particularly 
when complicating pneumonia and scarlet fever. The like- 
lihood of adherent pericardium resulting, which eventually 
produces myocarditis and dilatation, must be borne in mind. 

Treatment. — The child should be kept as quiet as possible 
during the active symptoms, and in case of recovery any phy- 
sical exertion must be forbidden until every danger from 
cardiac dilatation is past. The ice-bag applied to the prae- 
cordium is of decided advantage in older children. Purulent 
collections in the pericardium which fail to become absorbed 
rapidly are less favorably treated surgically than pleural effu- 
sions, for which reason every effort should be made to over- 
come this condition remedially before resorting to aspiration. 

Aeon. — Chilliness; hard, bounding pulse; sharp pain in 
region of heart ; great restlessness and sighing ; dyspnoea 
and syncope. Useful in the earliest stages to control the 
vascular excitement. 

Arsen. — Great anguish and oppression ; constantly chang- 
ing position ; cyanosis ; thirst ; in consequence of repelled 
exanthems, or in connection with pneumonia ; stage of 
effusion. 

23 



.346 DISEASES OF CHILDREN. 

Bryonia. — This remedy follows well after Aconite, and is 
most applicable during the stage of effusion, although it 
seldom absorbs the exudate completely. Sulphur is a most 
valuable remedy for this purpose, especially when the case be- 
comes protracted. 

Cactus grand. — Sensation of constriction about the heart, 
as if a strong hand were grasping it. There may also be a 
sense of deep-seated soreness in the prsecordium, with dysp- 
noea ; attacks of suffocation ; fainting ; small, irregular pulse. 

Digitalis. — Copious serous effusion ; small, intermitting 
pulse ; diarrhoea and vomiting ; syncope. 

Ioolium. — Complicating croupous pneumonia. Violent 
palpitation and oppression from slightest motion ; must lie 
perfectly quiet on back. 

Spigelia. — After Aconite, when the friction-sound becomes 
audible. Sharp, stitching pains in chest. Spigelia is a most 
efficient remedy for the painful stage. 

Besides these are to be considered Asclepias tuberosa, Bell., 
Cannab., Canth., Kali carb., Lack., Merc, cor., Veratr. vir. 

ENDOCARDITIS. 

Endocarditis is more liable to develop during the course of 
a rheumatic fever in children than in adults, but as the rheu- 
matic condition is not as typical in children as in adults, this 
relationship is often overlooked. Likewise endocarditis is 
frequently associated with chorea and erythema nodosum, 
and recurring crops of subcutaneous fibrous nodules about 
the joints are taken as an indication of a progressive cardiac 
affection. Packard (Amer. Jour. Med. Sci., Jan., 1900) notes 
five cases of acute tonsillitis and pharyngitis having no con- 
nection with rheumatism or any of its manifestations, in 
which endocarditis developed. While in these cases toxins 
absorbed from the throat might have set up structural 
changes in the endocardium by coagulation-necrosis or 
other chemico-vital action, still he inclines to the belief that 
the endocardium is directly infected with micro-organisms, 



DISEASES OF THE HEART AND ITS MEMBRANES. 347 

they gaining entrance by way of the tonsils. In support of 
this view is Charrius' case in which the staphylococcus 
aureus was found, both in the tonsils and in the endocardial 
vegetations. 

Endocarditis is, therefore, in all probability, of infectious 
origin, being the result of infection with pyogenic cocci or 
with the pneumococcus of Frankel. The tubercle bacillus 
may also set up acute endocarditis (Von Ruck). In simple 
endocarditis Sanger and Frankel have been able to demon- 
strate bacteria, and, according to Eichhorst {Specie lie Pathol- 
ogie n. Therapie), no distinction can be made between the 
group of micro-organisms capable of exciting the ulcerative 
variety in one case and simple endocarditis in another. The 
frequency with which the endocardium is attacked during the 
course of a rheumatic fever is readily interpreted by accepting 
in acute rheumatism an infectious disease, the result of spe- 
cific bacteria, which attack with preference the serous mem- 
branes. Meyer {Zeitschr. f. Klin. Medicin., Band Ixvi., p. 
311) found verrucose endocarditis present in twenty-one of 
one hundred animals injected with his diplostreptococcus. 
This micro-organism is probably identical with the one Poyn- 
ton and Payne claim to be the cause of rheumatic fever. 

Outside of rheumatism, endocarditis is seen with scarlatina, 
pneumonia, diphtheria, nephritis and septicaemia, in which 
case it is usually of a severe type. The ulcerative variety is 
also frequently associated with wound infection, and always 
partakes of the nature of a septic condition. 

In simple or verrucose endocarditis the valves become cov- 
ered with inflammatory excrescences — endocardial vegetations. 
( )wing to destructive changes in the endothelial cells and com 
sequent roughing of the surface of the valves these fibrinous 
formations are deposited fiom the circulating blood. At the 
same time the valves become thickened and distorted from 
interstitial cellular proliferation and vascular engorgement. 
Portions of the fibrinous vegetations may become detached 
and be swept into the general circulation, producing an em- 



348 DISEASES OF CHILDREN. 

bolus at some distant point. The mitral valve is the most 
frequent seat of the endocarditic process, next in frequency 
being the aortic valves. Right-sided endocarditis has been 
discussed under Fcetal Endocarditis. 

In malignant, or ulcerative endocarditis the inflammatory 
state is more pronounced, being coupled with ulcerative and 
even suppurative processes in the endocardium. 

Symptoms. — The onset of an endocarditis is always insid- 
ious, and especially when complicating another acute affec- 
tion is its presence likely to be overlooked. Again, children 
rarely complain of pain or distress in the region of the heart, 
and a primary case may run its entire course unrecognized, 
being mistaken for some infectious disease, such as influenza 
or rheumatism. When associated with tonsillitis it is fre- 
quently overlooked. Subacute cases may run a long time 
with slight afternoon rise of temperature, progressive anaemia 
and loss of weight. Such cases are easily confused with 
tuberculosis and malaria. A routine examination of the heart 
in all febrile conditions is, therefore, imperative. 

Endocarditis should be suspected if, during an acute infec- 
tious disease, there is an abrupt rise in the temperature with 
increased and weak pulse, precordial distress and dyspnoea. 
In children of the rheumatic diathesis, a fever rapidly attain- 
ing a height of 104 ° to 105 , together with tonsillitis, is fre- 
quently accompanied by a severe endocarditis in the absence 
of all articular symptoms. The pulse, which at first is strong 
and possibly slow in comparison to the temperature range, 
soon becomes rapid and feeble, even dicrotic. A certain 
amount of myocarditis always accompanies endocarditis, and 
when cardiac weakness becomes extreme it should be sus- 
pected as a co-existing condition. 

Praecordial distress and dyspnoea may be present, which, 
together with flushed face and the peculiarity of the pulse 
above referred to, are strong indications of this disease. The 
distress sometimes amounts to actual pain, which in young 
children may be referred to the epigastrium. 



DISEASES OF THE HEART AND ITS MEMBRANES. 



349 



The pathognomonic symptom of endocarditis is the charac- 
teristic bruit, also described as the bellows murmur from its 
soft, blowing character. The murmur is systolic and is heard 
best at the apex. Endocarditis may, however, exist without 
this murmur being perceptible, as the subsequent course of 
the disease will show ; and, again, during the infectious fevers 
a murmur is frequently heard, but it disappears during con- 
valescence, leaving no trace of valvular defect behind, an 




BIG. 43- 



ACUTE RHEUMATIC ENDOCARDITIS WITH DILATATION*; 
CYANOSIS AND DYSPNOEA MARKED. 



autopsy entirely failing in these cases to demonstrate an in- 
flammatory condition. If we study the murmur from day to 
day, we find that it gradually increases in loudness and dis- 
tinctness, the first indication of its advent being a prolonga- 
tion and blurring of the first sound of the heart. 

According to Dr. O. Sturges (Ashby and IVright), a faint 
murmur heard at the top of the ensiform cartilage, indicating 



350 DISEASES OF CHILDREN. . 

regurgitation at the tricuspid orifice, due to back pressure 
through the lungs, can in some cases be heard to precede the 
mitral bruit. 

With malignant or ulcerative endocarditis the symptoms of 
septicaemia become prominent; the temperature is intermit- 
tent, and there is enlargement of the spleen and albuminuria, 
beside a strong tendency to embolus formation in the brain or 
in other important organs. Such cases are fatal, as a rule, 
while in a well-managed case of simple endocarditis the prog- 
nosis as to life is always favorable, but the ultimate outcome 
as regards permanent valvular defects is a question. There 
is no doubt that in some cases, under proper treatment, the 
murmur will entirely disappear and there will be no evidence 
of valvular leakage or obstruction later on. On the other 
hand, endocarditis may produce such general damage to the 
endocardium as to blight the child's existence permanently 
and lead to early death. A comparatively slight lesion, also, 
by producing mitral stenosis, will do much more harm than 
one simply causing a leak at this valve. Another important 
point to be remembered is the strong tendency to recurrence 
in endocarditis, especially in rheumatic subjects. Every new 
attack adds to the existing damage. 

Treatment.— An essential element in the successful treat- 
ment of endocarditis is absolute rest, as any physical exertion 
capable of exciting the heart to increased action will neces- 
sarily exert a baneful influence upon the inflammatory pro- 
cess. The body surface must be carefully protected against 
chilling influences, and long-continued rest, even during con- 
valescence, is at times imperative, particularly when myocar- 
ditis is suspected. 

The ice-bag applied for fifteen minutes to half an hour, 
every two hours, is a valuable adjuvant during the acute 
stage. 

Prophylaxis is of importance. Children subject to rheu- 
matism should be kept under constant vigilance, and their 
diet and dress carefully regulated. Enlarged tonsils and ade- 
noids should be removed. 



DISEASES OF THE HEART AND ITS MEMBRANES. 351 

Aconite, Belladonna and Veratrum viride in the early 
stages, and later Spigelia, Spongia, Cactus, Bryonia and Col- 
chicum, are the most important remedies. After the acute 
symptoms have subsided much of the damage to the heart 
naturally to be expected can be prevented and overcome by 
the judicious choice of a remedy capable of absorbing the in- 
flammatory products and correcting the resulting disturbances. 
It is not difficult to obtain sufficient data for such a prescrip- 
tion, and here Aurum, Iodium, Spongia, Sulphur, Calc. card., 
Lachesis, Arsenicum and Arsenicum tod. are the most fre- 
quently indicated drugs. Kali mur. exerts a specific, action 
upon the heart-muscle, and is recommended to avert dilatation 
(Arnulphy). 

Aeon. — Chilliness; hard, wiry pulse with high fever, rest- 
lessness and dyspnoea. Veratrum viride has less of the rest- 
lessness ; the arterial tension is extreme and cerebral symp- 
toms may supervene, and, although it controls excessive car- 
diac action promptly, its influence upon the inflammatory 
process and the fever is inferior to that of Aconite. 

Belladonna. — Full, bounding pulse, flushed face, skin hot 
and moist, delirium. 

Bryonia. — Purely rheumatic cases; pericarditis and endo- 
carditis; sharp pains at heart, relieved by lying upon the 
affected side ; tongue dry and coated ; great thirst ; no desire 
to move. 

Cactus. — Sense of constriction in region of heart ; oppres- 
sion of breathing. (See Pericarditis.) 

Colchicum. — Rheumatic endocarditis ; tearing pain in region 
of heart; small, thready pulse (JousSET). 

Iodium. — Purring sensation in region of heart on palpation ; 
violent palpitation and dyspnoea, even to fainting, on slight- 
est exertion, with pneumonia ; if Spigelia does not give relief 
within a reasonable period of time (Kafka). 

Kali carb. — Blowing systolic murmur with accentuated 
pulmonary sound ; pulmonary engorgement; weakness of the 
heart-muscle, with anasarca of feet and ankles; associated 
myocarditis ; after Bryonia. 



352 DISEASES OF CHILDREN. 

Spigelia. — Considered by some the most important remedy 
in endocarditis. It may be given as soon as the condition be- 
comes recognizable, in the absence of strong indications for 
another remedy. Personally I prefer Bryonia, as I consider 
it more closely related to the pathologic process. There is 
no doubt, however, that Spigelia is a most valuable remedy 
in many cases of acute heart pain. 

Spongia. — Paroxysms of oppression and pain in the heart ; 
inability to lie with the head low, or even complete inability 
to lie down on account of the choking paroxysms induced 
thereby. 

MYOCARDITIS. 

Acute degenerative and inflammatory changes in the heart- 
muscle are of frequent occurrence in the acute infections of 
childhood. The toxins of diphtheria, scarlet fever and ty- 
phoid fever are especially concerned in the production of my- 
ocardial degeneration (Romberg). True inflammatory 
changes — myocarditis — are most frequently associated with 
endo- and pericarditis, and are due to the invasion of the 
heart-wall with pyogenic organisms, chiefly the streptococcus 
pyogenes, staphylococci and the pneumococcus (Ziegler). 
Myocardial changes have also been observed in whooping- 
cough by Koplik and Osier. Pyrexia is a contributing cause, 
but does not seem able to produce myocarditis by itself. 

The varieties of degeneration encountered are granular, 
hyaline and vacuolar. All of them may have more or less 
fatty changes associated. The process may be purely degen- 
erative throughout, but, as a rule, exudation and cell prolifer- 
ation in the connective tissue stroma is associated therewith. 
In infectious and pysemic cases areas of round cell infiltration 
play a prominent role, which may break down, resulting in 
small intramural abscesses. 

At autopsy the heart is found of a pale, yellowish-brown, 
turbid color and the muscle is easily torn. It is the soft-heart 
of the older writers. The process is mostly diffuse, although 



DISEASES OF THE HEART AND ITS MEMBRANES. 353 

in true myocarditis the changes may be more pronounced in 
different areas. 

The symptoms are essentially those of a weak heart. When 
myocarditis develops during the course of typhoid fever or 
pneumonia we realize that the pulse is too thin and rapid, the 
disproportion in the respiratory ratio too pronounced, and 
the first sound too weak to be accounted for merely by the 
fever. In the absence of demonstrable peri- and endocarditis 
we feel that here we have to deal with a degenerated myocar- 
dium. In the course of diphtheria the child is suddenly 
seized with epigastric pain, vomiting, syncope; rapid, irregu- 
lar pulse. A much worse prognosis than such a condition 
cannot well be named. 

The softening of the heart-muscle invites dilatation ; there 
is, therefore, usually some dilatation, especially of the right 
ventricle. A faint apical systolic murmur may be present. 
The heart is usually rapid and embryocardiac in rhythm. 
Bradycardia may develop, especially after diphtheria. On 
the other hand, there may be no symptoms, or only a short 
time before death w r ill there be sufficient indications to make 
us suspect myocarditis. 

Chronic myocarditis presents the symptoms described under 
Chronic Heart Disease as "failing compensation." 

The diagnosis of myocarditis cannot always be made during 
life, but there are certain symptoms that strongly point to its 
existence. The subject is well summarized by Koplik {Med. 
News, March, 1900) as follows: Attacks of faintness, pallor, 
vomiting; disturbed and irregular heart's action ; persistent 
distortion of the respiration and pulse-ratio as in adherent 
pericardium. When these attacks show a tendency to recur 
they are certainly significant. Physical examination reveals 
a weak apex-beat, weakness of the first sound or loss of its 
muscular quality, greater intensity of the second sound at the 
apex and accentuation of the pulmonary second sound. In 
pertussis there is in addition slight systolic blow at the apex, 
oedema of the face and extremities, pallor, cyanosis and drow- 
siness. 



354 DISEASES OF CHILDREN. 

The prognosis is grave. Under long-continued rest the 
heart may regenerate sufficiently to resume its function as 
before, providing the changes have not been too extensive. 
The symptoms described as indicative of myocarditis are in 
reality due to dilatation (OSLER). The abrupt death in the 
course of an acute infectious disease results from cardiac 
paralysis. 

The treatment calls for the most complete rest. As long 
as symptoms show the slightest tendency to recur the child 
should not be permitted to feed itself or make the slightest 
physical exertion. The remedy most homoeopathic to the 
degenerative changes is Phosphorus^ and it is no doubt of 
value. I have certainly seen it benefit cases of this class. 
Alcohol should at the same time be given in moderate 
amounts. As an emergency remedy, Holt speaks highly of 
Morphia. 

CHRONIC VALVULAR DISEASE. 

Chronic acquired valvular disease is the sequel to inflam- 
matory affections of this organ, notably acute endocarditis. 
The lesions which may be encountered are : (a) Thickening 
and distortion of the valves; (b) Fibrinous or calcareous de- 
posits upon the valve-leaflets; (c) Hypertrophy of the walls; 
(d) Dilatation of the chambers; (e) Adherent pericardium. 
These changes are usually seen in various stages of develop- 
ment, and in pronounced cases they may all be demonstrated 
in different portions of the organ. The mitral valve is by far 
the most frequently affected seat of lesion, the aortic valve 
being rarely affected in children, and, when so, more often in 
association with mitral disease than alone. The changes in 
the valves above referred to lead either to regurgitation or 
obstruction at the orifices. Both conditions may exist at one 
orifice, so that it is not uncommon to find mitral stenosis and 
regurgitation in the same patient. 

Symptoms. — The history of an organic heart affection can 
be described in three stages, constituting the classical course 



DISEASES OF THE HEART AND ITS MEMBRANES. 355 

pursued by this disease. T\\ejirst stage marks the onset, be- 
ing- the acute inflammatory stage, which leads either to im- 
mediate damage to the valves or to chronic endocarditis. 
The rheumatic diathesis underlies the vast majority of all 
cases of recurring or chronic endocarditis, and it is usually 
possible to obtain a previous history of rheumatic symptoms, 
such as recurring acute tonsillitis with joint pains, arthritis, 
erythema, fibrous nodul-es, chorea, etc., or to note the later 
development of one of these conditions in a case of valvular 
heart disease. 

The second stage is that of compensation, during which the 
heart adapts itself to the extra strain brought upon its mus- 
cular walls incident to the leakage or obstruction at its ori- 
fices. This is accomplished through hypertrophy of the ven- 
tricular walls, and a compensating heart is. therefore, usually 
an enlarged or hypertrophied organ. When compensation is 
perfect there are naturally no symptoms ; but as this is not 
always the case, the patient suffering more or less from short- 
ness of breath on exertion, palpitation, attacks of epistaxis, 
bronchitis, indigestion. 

TJiird stage. — The stage of failing compensation is the 
period at which the heart becomes incompetent to maintain 
the circulation, in consequence of which the arteries are but 
imperfectly filled with blood and the veins become engorged. 
Although the patient may be abruptly thrown into this stage 
by undue physical exertion or a fresh attack of endocarditis, 
pneumonia, typhoid fever or scarlet fever, still the usual 
course is that of progressively-increasing cardiac weakness, 
hastened by impairment of the general nutrition, anaemia, in- 
tercurrent diseases, etc. 

The symptoms of cardiac incompetency, when of gradual 
onset, will show themselves in dropsy of the lower extremi- 
ties; difficult breathing from the slightest physical exertion 
and when lying with the head low ; cough, with frothy, blood- 
streaked expectoration; flatulent indigestion; scanty, albu- 
minous urine of high specific origin. When of sudden onset 



356 DISEASES OF CHILDREN. 

there is marked dyspnoea and cyanosis ; the lnngs are the seat 
of venous engorgement, which frequently leads to pulmonary 
oedema and death. 

The imperfect circulation resulting from valvular disease 
interferes with the general nutrition and sets up important 
visceral changes. To the former belong clubbing of the fin- 
gers and stunted growth, and to the latter, chronic bronchitis, 
chronic congestion of the spleen, liver and kidneys. 

The prognosis of organic heart disease is never favorable, 
as complete recovery is impossible, and the possibility of re- 
newed attacks of endocarditis and other factors capable of 
rupturing compensation must be a constant menace to the 
child's condition. The course is usually a progressive one, 
and puberty seems to exert an unfavorable influence upon the 
disease. Nevertheless, well-managed cases may attain adult 
life with safety, and by the maintenance of a good general 
nutrition develop no serious symptoms. 

MITRAL REGURGITATION. 

Mitral regurgitation is the commonest valvular defect of 
childhood, resulting from distortion, and consequent imper- 
fect closure, of the mitral valve. Owing to the regurgitation 
of the blood into the left auricle, the same becomes hypertro- 
phied, and later dilated; the pulmonary circulation becomes 
embarrassed and an extra amount of work is thrown upon the 
right ventricle, which also hypertrophies in order to meet the 
extra strain upon its walls. The damming back of the blood 
in the pulmonary artery causes the accentuated second sound 
over the pulmonary valve, so characteristic of mitral regur- 
gitation. The left ventricle eventually hypertrophies, in con- 
sequence of the increased pressure in the pulmonary artery, 
against which it must work in order to sustain the circula- 
tion. Urgent symptoms are the result of failing right heart, 
the right ventricle often dilating to a great degree, even to 
the production of incompetency of the tricuspid valve. 

The physical signs of mitral regurgitation are a systolic 



DISEASES OF THE HEART AND ITS MEMBRANES. 357 

murmur heard with the greatest intensity at the apex and 
transmitted into the left axilla ; accentuated second sound 
over the pulmonary artery ; increased area of dulness to the 
right, indicating hypertrophy and dilatation of the right ven- 
tricle ; displacement downward and outward of the apex. 

MITRAL STENOSIS. 

Mitral stenosis is frequently associated with regurgitation, 
owing to a shrinkage of the valves and the auriculo-ventricular 
orifice, or obstruction resulting from fibrinous or calcareous 
deposits. In quite a number of instances, however, it exists 
alone, and in such cases it is generally associated with sub- 
acute rheumatism and insidious endocarditis. There are 
cases in which we can get absolutely no history of rheuma- 
tism or any other preceding infectious disease. 

A typical case of mitral stenosis is marked by dyspnoea ; 
small, feeble pulse ; dilatation of the left auricle, and hyper- 
trophy, with later dilatation of the right ventricle, the left 
ventricle not participating in the process unless regurgitation 
is associated. The physical signs are a presystolic murmur, 
which may assume a purring character, perceptible to the 
touch ; sharp, snappy first sound at the apex ; accentuated 
second sound over the pulmonary valve ; area of dulness in- 
creased upward and to the right. The presystolic thrill is 
the most characteristic of all signs in valvular heart disease, 
and upon this symptom alone — if we can exclude adherent 
pericardium — the diagnosis is readily made. It is best felt 
by placing the flat hand over the cardiac area, the thrill being 
plainest in the fourth interspace to the left of the sternum. 

Mitral stenosis is more frequently found in phthisical sub- 
jects than the other forms of valvular disease. Indeed, mitral 
regurgitation is looked upon as unfavorable to the develop- 
ment of phthisis. 



358 DISEASES OF CHILDREN. 



AORTIC STENOSIS. 

Stenosis of the aortic orifice results from pronounced at- 
tacks of endocarditis, for which reason it is one of the rarer 
organic affections and seldom seen alone, usually being asso- 
ciated with mitral regurgitation. From the nature of the 
lesions at the aortic orifice, regurgitation is also frequently 
added to the obstruction. Unless there is marked stenosis, 
symptoms are not prominent, as the hypertrophied left ven- 
tricle perfectly compensates for the defect. Complete recov- 
ery is possible. 

The physical signs are a systolic murmur heard over the 
aortic orifice and transmitted into the carotids; displacement 
of the apex downward and outward from hypertrophy of the 
left ventricle; slowing of the pulse. 

AORTIC REGURGITATION. 

Regurgitation of the aortic orifice, like stenosis, is rare in 
children, and is never observed as a single condition. The 
commonest causes for aortic regurgitation, namely, sclerosis 
of the valves due to syphilis, gout and alcoholism, are practi- 
cally never present in children, and for this reason it is only 
found with severe cases of endocarditis, especially the variety- 
complicating the infectious fevers, from which stenosis and 
mitral disease also result. In a case which came under my 
notice the valve was found unaffected by inflammatory de- 
posits at the autopsy. There was, however, mitral disease 
and dilatation. The insufficiency at the aorta was, therefore, 
most likely relative, i. <?., due to dilatation of the aortic orifice. 

As a result of the regurgitation of the blood into the left 
ventricle the same becomes markedly hypertrophied, later 
dilating with the consequent production of mitral regurgita- 
tion. 

The physical signs are a rapid, strong, full pulse, with sud- 
den collapse (Corrigan's pulse); a diastolic murmur at the 
aortic orifice; extension of cardiac dulness in the direction of 



DISEASES OF THE HEART AND ITS MEMBRANES. 359 

the heart's long axis and displacement of the apex-beat down- 
ward and outward; arched appearance in the region of the 
praecordium in young subjects ; strong, bounding pulsation of 
the carotids. The capillary pnlse can also be demonstrated 
at the matrix of the finger-nail or by pressing a glass slide 
against the forehead. Riesman has on several occasions 
noted pulsation of the uvula. The water-hammer pulse is 
best observed by grasping the forearm with both hands just 
above the wrist and holding it in a vertical position. The 
rebound, or diastolic shock, is then plainly felt. 

Treatment. — The child's general condition must be care- 
fully observed and physical overexertion strictly prohibited, 
in order to maintain as perfect a compensation as possible. 
Systematic exercise, with sufficient sleep and a highly nutri- 
tious, non-stimulating diet, and special attention to the digest- 
ive function, are the important considerations. 

Xo form of treatment has as yet exceeded in expectations 
the results obtained by the Schott method of baths and 
resisted movements, and when given in conjunction with 
remedies which may be called for upon general or special in- 
dications, this line of treatment will, no doubt, prove itself 
without equal. The effect of the bath, as described by Dr. 
Edward R. Snader (Hahncmanniaii Monthly* November, 
1898), is "to reduce the size of a dilated heart, diminish the 
number of pulse-beats, fill the arteries, partially empty the 
veins, open the cutaneous capillaries, and inaugurate a re- 
habilitation of a damaged heart-muscle by reason of nutri- 
tional change." That this change takes place in the heart 
has not only been repeatedly demonstrated by the skillful use 
of percussion, but it has also been actually shown by means 
of skiagraphs, personally made by Dr. Theodore Schott [Medi- 
cal Record, March 26, 1898). 

The advent of urgent symptoms as a result of ruptured 
compensation will at times require a purely physiological 
prescription to tide the case over. Pulmonary congestion due 
to overfilling of the right heart and general venous stagna- 



360 DISEASES OF CHILDREN. 

tion calls for Glonoin (drop-doses of the second decimal dilu- 
tion, repeated half hourly until relief is obtained), the action 
of which is well supplemented by Veratrum viride ix, given 
at less frequent intervals. A failing left ventricle is fre- 
quently rescued by the judicious use of Digitalis, in five-drop 
doses of the tincture, repeated in from three to four hours 
until results are obtained. Under no circumstances, however, 
should such treatment be extended beyond the critical period. 
Rest, tonic treatment and a carefully-chosen remedy must be 
relied upon to safely bring the patient back to a state of re- 
stored compensation. Ferrttm in one of its forms when there 
is anaemia and Cinchona to improve the appetite and general 
condition are indispensable. Dr. Snader highly lauds Cactus 
as a safe, efficient heart tonic, which may be used without 
fear of producing overstimulation or cumulative effects. 
The Iodide of Arsenic is also a valuable heart remedy when 
there is shortness of breath on exertion and slight oedema of 
the ankles. 

Attacks of sudden heart failure call for rapid-acting stimu- 
lants, such as Ammonia, the Alcoholics, and Nitroglycerin. 
The most positive results are obtained in these cases by the 
hypodermatic injection of Strychnia (one one-hundredth to 
one-fiftieth of a grain). 

Aeon. — Attacks of anxiety, pallor, restlessness, tingling in 
the extremities, small, thready pulse, fear of death. Also 
hacking cough, with stitching pains and haemoptysis accom- 
panying valvular disease. 

Arsenicum. — Cardiac weakness with precordial anguish 
and oppression ; inability to lie down ; nocturnal aggrava- 
tion ; anasarca of lower extremities. Arsenicum iod. em- 
bodies to a certain extent the properties of Arsenic and Iodine, 
both of which possess marked and characteristic cardiac 
symptoms in their pathogenesy. 

Cactus grand. — Cactus is quite extensively used in the 
first decimal dilution, and in the tincture, for its sustaining 
action upon the heart, being credited with the non-production 



DISEASES OF THE HEART AND ITS MEMBRANES. 361 

of cumulative or harmful effects. It is a valuable remedy in 
mitral disease with pains radiating down the left arm ; also 
sense of constriction about the heart ; small, feeble, intermit- 
tent pulse ; icy-cold feet. 

Convallaria. — Mitral stenosis, with dyspnoea and irregular 
heart action ; dilatation of the right ventricle. 

Digitalis. — Irregular, intermittent action of heart. During 
perfect rest the heart's action is slow, but the slightest exer- 
tion produces accelerated and irregular action. Sensation of 
complete arrest of heart's action. 

Gelsemium is similar in some respects to Digitalis. There 
is a feeling as if the heart would stop beating if he did not 
keep moving about ; also asynchronism of heart's action and 
cyanosis of the lips. 

Iodinm. — Violent palpitation from the slightest exertion. 
Shortness of breath, palpitation and feeling of weakness on 
going up-stairs ; constant heavy, oppressive pain in the region 
of the heart (Hering). 

Lachesis. — Awaken from sleep with sense of suffocation in 
throat ; cannot bear anything tight about throat ; venous con- 
gestion of internal organs ; dilated veinules on chest ; defect- 
ive peripheral circulation and tendency to cyanosis. 

Natritm mur. — Fluttering of the heart, with attacks of 
faintness ; irregular and intermittent heart's action ; anaemia. 

Phosphorus. — Tightness across the upper portion of the 
chest, with tight cough and spitting of blood ; weakness of 
the right heart, with venous stagnation ; cannot lie on the 
left side ; palpitation from every emotion, with rush of blood 
to the chest in rapidly developing children (Calc. phos.). 

Rhus tox. — Rheumatic affections ; hypertrophy from phy- 
sical overexertion, with palpitation and pain shooting from 
region of heart down the left arm. 

Spigclia. — Sharp, stitching pains in region of heart ; anx- 
iety and oppression when lying down ; can only sleep on the 
right side ; purring feeling over heart. Great dyspnoea 
at every change of position. 
24 



362 DISEASES OF CHILDREN. 

Spongia. — Attacks of oppression and cardiac pain when 
lying with head low ; suddenly awaking after midnight, with 
suffocation, great alarm, anxiety (Hering). Valvular insuf- 
fiency, pericarditis in stage of effusion and aneurism are 
within the scope of this remedy. 

In the dropsy of heart disease I have obtained the best re- 
sults from Apocynum cannabinum, twenty drops of the de- 
coction (BoERiCKE & Tafel's) three times daily. Swelling 
of the ankles and other minor conditions, simply pointing to 
a weak heart and sluggish venous circulation, yield very 
satisfactorily to such remedies as Arsenicum, Bryonia, Kali 
carb. and Lycopodium. Purgation may become necessary in 
pronounced cases, threatening the patient's life. 

FUNCTIONAL DISORDERS. 

As has already been pointed out, functional disorders of the 
heart are not very common during childhood. The most 
prominent causes of these disorders are gastro-intestinal irri- 
tation, helminthiasis, teething, anaemia, chorea and hysteria. 

The symptoms are various, the commonest type of disorder 
being irregularity of rhythm and intermission; palpitation 
with rapid breathing and attacks of syncope being next in 
order. Heart consciousness is obviously less common in chil- 
dren than in adults, and angina pectoris is quite a rare dis- 
ease. 

A case of neurotic angina pectoris in a girl ten years old was 
brought to my clinic at the Children's Homoeopathic Hos- 
pital. She was apparently in good health, having had no 
prior serious illness, and the family history was good, with 
the exception of rheumatism on the mother's side. There 
had been stitching pains in the heart for several weeks, and 
two weeks before she was seen the first paroxysm developed. 
The paroxysms then appeared at intervals of several days, be- 
ginning with a feeling of extreme tiredness and oppression 
about the heart, followed by sharp agonizing pains in the 
heart and pains radiating down both arms into the wrists, the 



DISEASES OF THE HEART AND ITS MEMBRANES. 363 

left one becoming affected first. The face became flushed, the 
pulse small and rapid, and the heart's action violent. Amyl 
nitrite inhalations immediately controlled the paroxysms, and 
as she had three in succession at the hospital the diagnosis 
could be readily confirmed. Under the administration of 
Spigelia there was no further return of the trouble. 

The treatment of functional heart affections is mainly hy- 
gienic, coupled with the administration of such remedies as 
Aconite, Belladonna, Cactus, Digitalis, Kalrnia, Nux vomica, 
Pulsatilla, Rhits tox. and Spigelia. The child's general con- 
dition must be looked after, and if helminthiasis, intestinal 
catarrh, lithaemia or any other exciting cause can be dis- 
covered, treatment should be instituted in that direction. 



CHAPTER XIII. 

DISEASES OF THE KIDNEYS AND URINARY TRACT. 

Nephritis complicating the infectious fevers is the most fre- 
quent form of renal disease encountered during childhood. 
Malformations are occasionally encountered at autopsy but 
cannot be diagnosed. Innocent fibromata, adenomata and 
cystic degenerations are occasionally met with, and outside of 
hsematuria produce no characteristic symptoms, unless they 
attract attention by attaining considerable size. Infants with 
cystic kidneys die shortly after birth as a rule. The condi- 
tion is almost always bilateral. 

Malignant tumors are most frequently sarcomata and have a 
tendency to grow very rapidly. Carcinoma of the kidney is 
also relatively common in children. It is estimated that 38 
per cent, of all new growths of the kidney reported occurred 
in children (Lewi). Hydronephrosis may occur during child- 
hood; cases have been observed which evidently depended 
upon phimosis. 

The kidney in the infant is about twice as large — com- 
pared with the body weight — as in the adult. In shape it is 
more lobulated. In the new-born, deposits of sodium urate — 
uric acid infarcts — are frequently encountered in the tubules 
on making a section of the organ. The kidneys can occa- 
sionally be palpated in children with flabby abdominal walls 
and lax tissues, especially in the rachitic, the right kidney 
being the most accessible. It is hardly fair to speak of such 
a condition as floating kidney, but a number of authentic 
cases of this nature have been recorded. Koplik speaks of a 
case in a girl eight years old in which there was present epi- 
gastric pain and hysterical manifestations. 

The urine must be studied both from the chemical and 
microscopic standpoint and the frequency of urination. Total 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 365 

daily quantity, the presence of pain, fever, loss of control over 
the bladder and association of other symptoms pointing to im- 
paired renal function must also be taken into consideration in 
making a diagnosis in diseases of the urinary tract. During 
infancy there is a relatively larger quantity of urine excreted 
than later in life. Standard figures cannot be given, but the 
amount gradually increases from one ounce or more in the 
first week of life to about twenty ounces at the completion of 
dentition, and thirty-six ounces just prior to puberty. 

The frequency of urination depends upon the age, and, to a 
less extent, upon such modifying influences as sleep, tempera- 
ment and habit. Concerning the control over micturition, 
Ulzmann (Genito-Urinary Neuroses) writes: "In the earliest 
childhood urination and defecation take place without any 
subjective sensations. The slightest contraction of the blad- 
der and of the rectum suffices to expel the urine and faeces, 
since the resistance of the sphincters is wanting. After the 
first year of life children begin to voluntarily hold back the 
faeces, while the urine still flows involuntarily, often against 
the will of the little ones. The ability to hold the urine back 
at will is usually established at about the end of the second 
year, that is, after the first dentition." 

The specific gravity is lower than in adults, and the urine 
contains a greater percentage of uric acid, but less urea and 
inorganic salts. It is usually clear, but may be turbid from 
the presence of mucus and white urates. 

The method of collecting the urine for examination has been 
described in the chapter on "Clinical Examination." 

ALBUMINURIA; CYCLIC ALBUMINURIA. 

Albuminuria not traceable to nephritis is encountered in 
two forms, namely, idiopathic albuminuria and acute degener- 
ation of the kidneys. The former condition is also known as 
cyclic or orthostatic albuminuria. The latter name well ex- 
presses the nature of this form of albuminuria, which disap- 
pears on complete rest and reappears after the patient has 



366 DISEASES OF CHILDREN. 

been up and about for some time. Physical exertion increases 
the amount of albumin. It is most frequently seen in male 
children who are anaemic or neurotic, and develops during 
adolescence. Heubner looks upon cyclic albuminuria as a 
condition without danger that ultimately disappears, while 
Senator thinks that it always indicates some insidious struc- 
tural changes in the renal parenchyma. It is difficult to say 
in the beginning just how a case will terminate. 

Acute degeneration of the kidneys occurs during the infec- 
tious fevers, especially in scarlet fever, diphtheria, pneumo- 
nia and typhoid fever. Henoch has also repeatedly seen this 
condition in autopsies upon atrophic children, children dying 
from diseases characterized by marked loss of vital fluids, e. 
g., cholera infantum, intestinal tuberculosis, etc., and after 
prolonged high temperature. Morse {American Med., April 
5, 1902) found acute degenerative nephritis in 15 per cent, of 
a series of seventy cases of enteric diseases in infants. No 
symptoms outside of the urinary findings were present to sug- 
gest the condition. Personally, I have not seen decided 
structural kidney changes in autopsies upon infants dying of 
enteritis as frequently as some writers report. 

Certain poisons, like Arsenic and Phosphorus, and many 
drugs, notably Cantharis and Turpentine, act upon the renal 
epithelium while being eliminated. The local as well as the 
internal use of Bichloride of Mercury is frequently attended 
with albuminuria. It is questionable whether there be such 
a condition as febrile albuminuria, where the action of toxins 
can be excluded. 

The kidney appears slightly swollen, and the cortical sub- 
stance presents a grayish appearance, which may advance to 
fatty changes. Microscopically the epithelial cells of the 
tubules are the seat of cloudy swelling. 

The prognosis is favorable in both conditions. In idio- 
pathic albuminuria much can be done by constitutional treat- 
ment. The diet is of great importance, and frequently a re- 
striction to farinaceous foods, fish, fruit and fats suffices to 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 367 

clear up the albuminuria, as demonstrated by Fothergill 
(Manual of Dietetics). Where, however, the patient is poorly 
nourished, a tonic treatment must be instituted, together with 
the constitutional remedy. Febrile albuminuria clears up 
with the recovery from the disease which has induced it. 
Nitrogenous food must be withheld during its course, and in 
the absence of strong indications for another remedy, one of 
the following should be selected : 

Apis, Arsen., Canth., Merc, cor., Terebinth. For special 
indications, see Treatment of Acute Nephritis. 

CEDEMA WITHOUT KIDNEY LESION. 

In protracted cases of enteric disturbances it is not uncom- 
mon to find more or less general oedema without the slightest 
trace of nephritis. There is puffiness of the eyelids and a 
cushion-like swelling on the dorsum of the hands and feet. 
It may even involve the extremities. This is associated with 
anaemia and feeble circulation. It is undoubtedly only a 
symptom of weakness. Changes in the lymphatic system re- 
sulting from the absorption of toxins are held to exist by 
some writers. 

In all conditions of anaemia, notably in chlorosis and hy- 
draemia, there is a tendency to anasarca. In the terminal 
stage of tuberculosis we often see it. 

HEMATURIA ; HEMOGLOBINURIA. 

Hematuria, or blood in the urine, has the same significance 
in infancy as in later life, although it is much less frequently 
due to organic and mechanical causes (papilloma, calculus) 
than to acute nephritis, tuberculous cystitis and general dis- 
turbances, such as haemorrhagic disease of the new-born, 
purpura, scurvy. Of the last named condition it may be the 
first and most prominent symptom ; in fact, the only symptom. 

Hemoglobinuria, or haemoglobin in the urine, results from 
the action of some toxic agent or ferment upon the blood, 
through which the haemoglobin is dissolved out of the cor- 
puscles and excreted with the urine. 



368 DISEASES OF CHILDREN. 

It has been observed in various infections (malaria, scarlet 
fever), in helminthiasis, after exposure to cold and as a result 
of certain drugs {Potassium chlorate, Phosphorus, Arsenic]- 
The most striking form is recurring hemoglobinuria. This 
usually affects children whose health is below par, and in 
many cases there is a history of hereditary syphilis. I have 
had such a case under observation for a long time. This 
child also had scarlet fever. The attacks occur at irregular 
intervals and are associated with anorexia, malaise and other 
general disturbances. The urine is of a dark reddish-brown 
color, high specific gravity and contains albumin. The dis- 
ease is usually outgrown. 

The treatment is symptomatic. 

ACUTE NEPHRITIS. 

Pathologically, two forms of acute nephritis may be dis- 
tinguished, based upon the intensity and location of the in- 
flammatory process. In the milder form there is congestion 
of the kidneys, with exudation of blood plasma and leucocytes, 
and degeneration of the epithelium of the urinary tubules and 
glomeruli. For this variety Delafield has chosen the name 
acute exudative nephritis, while the more extensive inflam- 
mation, in which the stroma and glomeruli are involved in 
permanent pathological changes, he designates as acute pro- 
ductive nephritis. Here there is, beside the exudation, a 
growth of the capsule cells of the Malpighian bodies. This 
form of nephritis is especially common in older children, oc- 
curring as a complication of diphtheria and scarlet fever 
(Councilman). 

Macroscopically the kidney may show but slight evidence 
of congestion or degenerative changes. Usually it is swollen ; 
softer and more moist than normal. The cut surface is gray- 
ish or mottled red, indicating degenerative changes and 
alterations in the distribution of the blood. The cortex 
is light or yellowish-gray, while the medullar) 7 portion 
(pyramids) is cyanotic. The glomeruli may be seen as red or 
grayish points. 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 369 

Etiology. — The relation of the nephritis of childhood to in- 
fectious fevers is almost an inseparable link ; indeed, cases 
not traceable to one of these fevers are looked upon as the re- 
sult of an infection of unknown origin. A few cases of 
primary nephritis are on record. The most important con- 
tribution on this subject is from Holt {Archives of Pediatrics, 
1887). In this form of nephritis the renal symptoms may be 
insignificant as compared with other associated symptoms 
such as enteric disturbances, for which reason it is no doubt 
frequently overlooked. 

The pathological changes taking place in the kidney 
parenchyma vary with both the virulence and the amount of 
toxin circulating in the blood and are as follows : Acute de- 
generation ; acute exudative nephritis; acute productive 
nephritis. 

The first-named condition is the primary result of the 
toxins, and, if the irritation is not prolonged beyond a certain 
point, it will be the only pathological change taking place. 
Acute degeneration, therefore, appears in the early stages of in- 
fectious fevers. 

Should, however, the irritation be prolonged, or the excit- 
ing cause be quite energetic in action from the beginning, a 
true exudate inflammation will be the result. For this reason 
actual nephritis is usually a later occurrence in the course of 
the fever. 

The productive type of nephritis is a more diffuse inflam- 
mation, more subacute in its type, and most frequently fol- 
lows upon scarlet fever, as a result of the powerful kidney- 
poison peculiar to this disease. Pneumonia is more likely to 
produce nephritis in childhood than in adult life. The same 
may be said of influenza. 

Aside from the clearly infectious cases, nephritis has been 
attributed to catching cold from exposure to draughts or living 
in cold, damp dwellings ; the presence of bile-acids in the 
blood ; diphtheria antitoxin injections, and to the use of 
many well-known drugs. 



370 DISEASES OF CHILDREN. 

Symptomatology. — Occurring early in the course of a 
severe infectious fever, the presence of albumin in the urine, 
together with a few hyaline or granular casts, indicates 
nothing beyond an acute degeneration of the kidneys. This 
may also occur during prolonged high fever ; but when a 
true nephiitis develops there are added the symptoms of 
dropsy, scanty urine, increased fever, and the presence of 
renal epithelium, blood, leucocytes, hyaline and granular 
casts. 

A primary nephritis is ushered in with high fever, pain in 
the region of the kidneys, headache and vomiting, scanty 
urine and dropsy. 

When secondary to an infectious fever the symptoms de- 
velop less abruptly. They make their appearance at the 
height of the fever or during convalescence as sometimes 
takes place in scarlatina. Frequently a renal affection is not 
suspected until dropsy and scanty urine become prominent, 
or until the protracted course of the disease leads to an ex- 
amination of the urine, when the mystery becomes solved. 
Post-scarlatinal nephritis appears, as a rule, in the third or 
fourth week of the disease. 

Dropsy is naturally most noticeable in those portions of the 
body possessed of loose areolar tissue, and for this reason the 
face, particularly the eyelids, the wrists and ankles, legs and 
scrotum, become most markedly affected. The pleural and 
peritoneal sacs are involved in grave cases. (See Fig. 44.) 

Dilatation of the heart, indicated by an increase in the area 
of cardiac dulness and weak pulse, is a frequent complication 
arising during the course of nephritis. The urine is dimin- 
ished in quantity, the specific gravity high, although the 
amount of solids excreted is far below the normal. Its color 
is dark-red or smoky, the latter indicating the admixture of 
renal blood, and it contains albumin in abundance ; blood ; 
leucocytes; renal epithelium and casts. Early there will be 
blood and narrow hyaline casts ; later epithelial, granular and 
broader hyaline casts. 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 



371 



Prognosis. — The absence of complete suppression of urine 
and uraemia, (the latter condition manifesting itself as severe 
headache and vomiting, followed by coma and general con- 
vulsions,) and the speedy control of the anasarca, with ab- 
sence of extensive pleural effusions and oedema of the glottis, 
offers a favorable prognosis as far as the acute condition is 
concerned. 

Long-continued anaemia and albuminuria indicate inter- 
stitial and destructive changes in the kidney structure, but in 
view of the fact that the child's kidney possesses marked re- 
generative power, recovery can often be expected under 
extreme care in hygienic measures and in the selection of 




FIG. 44. — A CASE OF ACUTE (POST-SCARI^ATINAI.) NEPHRITIS 
WITH ANASARCA AND ASCITES. 



remedies. It is, indeed, remarkable to witness the evidently 
complete recovery that so frequently takes place in severe 
nephritis. 

Our therapeutic resources are particularly rich in the symp- 
tomatology of renal affections, both for the acute as well as 
more permanent changes taking place in the kidney, and the 
results of careful prescribing are most gratifying. 

Treatment. — As most of the cases develop during one of 
the infectious fevers, prophylactic measures stand high in the 
therapy of nephritis. These must aim to spare the kidneys 
as much as possible from any extra amount of work and from 



372 DISEASES OF CHILDREN. 

the danger attending congestion of these organs, the practice 
of which resolves itself into the elimination of highly nitro- 
genized foods from the dietary ; a maintenance of the normal 
cutaneous function, or even a stimulation of the same ; rest 
in bed and protection against chilling influences. Especially 
in scarlet fever is it imperative to keep the child in bed for 
from three to six weeks, according to the severity of the case, 
and return most cautiously to a diet of solid food 

The free use of boiled water and the daily warm bath to 
induce gentle sweating under a woolen blanket is a great aid 
to the kidneys, and frequently all-sufficient to overcome 
moderate anasarca. Suppression of urine and uraemic mani- 
festations call for the hot pack. In the presence of anasarca 
and suppression of urine the drinking of water must be tem- 
porarily cut down to a minimum. Goodno recommends the 
hot-air bath in these cases. 

Personally, I place the greatest reliance upon hot high 
rectal enemata in conjunction with the hot pack in acute 
nephritis with suppressed or scanty urine and uraemic symp- 
toms (vomiting ; cerebral irritation). These injections act 
as a stimulant to the abdominal sympathetic and by inducing 
free diuresis relieve the renal congestion and eliminate toxins. 
The diet should consist mainly of milk, and in no case should 
meat, eggs or strong broths be administered. Cereals and 
stewed fruit may be selected as solid food is gradually resumed. 

Owing to the fact that the nephritis is usually secondary 
to some other condition, our indications for a remedy are not 
so sharply defined as in the primary form of adults. 

Arsenicum is indicated by the great anaemia and anasarca, 
especially prominent about the eyelids in the morning. There 
is scanty urine, the characteristic thirst and restlessness, and 
cardiac involvement. 

Apis is frequently called for, and is most useful for condi- 
tions which arise suddenly, especially during the course of 
some other disease ; the urine becomes scanty or suppressed, 
general dropsy develops, and oedema of the glottis may 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 373 

threaten ; cerebral involvement, with coma, shrill, piercing 
cry, and convulsions. 

Cantharis is highly lauded by both schools of medicine. 
It is useful for the very acute symptoms which may arise, 
such as high fever, tearing pains in the kidneys, vesical 
tenesmus, retention of urine and ursemic coma ; also in the 
later stages, to remove the albumin from the urine. 

Hepar. — Urine decreased in quantity and containing blood, 
albumin and hyaline casts. Kafka's experience was : " No 
remedy will act quicker or surer than Hepar salph. 3 in the 
case of dropsy and albuminuria occurring during scarlet 
fever " {Homccopatische Therapie). His reason for using this 
remedy was on the grounds of the relationship of Hepar to 
croupous inflammation. 

Lachesis and Terebinthina r especially the latter in post-scar- 
latinal nephritis, are indicated in hsemorrhagic nephritis. 
In Lachesis the urine is very dark in color, and the character- 
istic subjective symptoms of the drug may be present. The 
urine indicating Terebinth, is highly albuminous and scanty, 
the color being " smoky," due to the abundant admixture of 
blood. Helleb. is also prominent in hematuria. 

Ursemic convulsions call for Cicuta, Bell., Hyos. or Stra- 
monium ; the Arsenite of Copper seems particularly appli- 
cable to all forms of ursemic conditions and is the remedy 
most to be relied upon. 

All complications, such as serous effusions, oedema of the 
lung, etc., must be dealt with purely symptomatically. The 
resulting anaemia most frequently calls for Arsen., Kali ' carb., 
Phosphorus. 

CHRONIC NEPHRITIS ; BRIGHT'S DISEASE. 

Chronic nephritis may develop as a result of former acute 
conditions, especially after post-scarlatinal productive nephri- 
tis ; but more commonly it complicates other important dis- 
turbances, prominently general tuberculosis ; tuberculous- 
caries ; long-continued suppurative processes and hereditary 
syphilis. Heredity also may be an etiologic factor. 



374 DISEASES OF CHILDREN. 

Both pathologically and clinically chronic nephritis may be 
classed into two distinct varieties, namely, chronic praenchy- 
matous and chronic interstitial nephritis. 

CHRONIC PARENCHYMATOUS NEPHRITIS. 

In this form the kidney becomes much enlarged, present- 
ing a yellowish-white appearance (large white kidney). On 
section, the cortex will be found thickened and swollen and 
light in color, while the pyramids retain their dark-red hue. 

The epithelium of the tubules is swollen and degenerated ; 
the tubules contain degenerated cells and coagulated fibrin. 
Hyperplasia of the interstitial connective tissue and nuclear 
proliferation in the glomeruli and their capillaries, together 
with amyloid degeneration of the smaller vessels, are the his- 
tological lesions. Delafield sums up the pathology of the whole 
condition in the name he gives it, namely, chronic productive 
nephritis with exudation. Amyloid changes in the blood- 
vessels of the glomeruli are common in the nephritis of child- 
hood. 
- Symptomatology. — As a rule, the first symptoms which 
will give any evidence of a renal disturbance, outside of an 
accidental discovery of albumin and casts in the urine, will 
be dropsy. The history of a former attack of acute nephritis, 
especially when the child is markedly ansemic and passing an 
insufficient quantity of urine, should, however, lead to a 
suspicion of Bright's disease long before the more serious 
symptoms make their appearance. 

Anasarca usually develops suddenly, although the baggi- 
ness of the eyelids, especially in the morning, may for some 
time be the only manifestation. When marked, the child 
may become literally swollen from head to foot ; with this 
the urine is very scanty, or even suppressed. 

With the progress of the disease the quantity of urine de- 
creases and becomes turbid from the presence of inflammatory 
products, urates, and sometimes blood. Albumin is found 
abundantly, and a microscopic examination reveals de- 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 375 

generated epithelium, hyaline, granular, epithelial, and, at 
times, fatty casts. The specific gravity is below normal. 

The course of the disease may extend over years ; and al- 
though much more can be done for children than for adults, 
especially in recent and subacute cases, still the prognosis in 
a fully established case of advanced nephritis with especial 
involvement of the parenchyma of this important organ can 
offer nothing but the most unfavorable prognosis, death ulti- 
mately occurring from uraemia or seme intercurrent affection 
(pneumonia). The exact duration is hard to predict, as the 
course is irregular and marked by improvement and exacer- 
bations. 




FIG. 45. — CHILD THREE YEARS OLD J CHRONIC PARENCHYMATOUS 
NEPHRITIS WITH ANASARCA AND ASCITES. 



Associated symptoms are anaemia, lassitude, indigestion, 
headache, and kindred nervous disturbances. Dropsical ef- 
fusions into the peritoneal cavity, the pleura or pericardium 
may take place. 

Urczmia is usually ushered in by severe headache and 
vomiting, followed by convulsions and coma. In children 
convulsions are more common than in adults, for obvious 
reasons. Uraemia is not so liable to develop when amyloid 
changes are marked in the kidneys, which can be suspected 
from the freer urinary secretion and the coexisting enlarged 
liver and diarrhoea. 



376 DISEASES OF CHILDREN. 

CHRONIC INTERSTITIAL NEPHRITIS. 

This is a rare form of nephritis in children, and its etiology 
is not well understood. Syphilis, tuberculosis, acute alcohol- 
ism and arterio-sclerosis have been considered as causes, and 
in some instances it has apparently followed in the wake of 
an acute infectious or eruptive fever. Allan Baines {Archives 
of Pediatrics, 1901) reports a pronounced case of arterio- 
sclerosis with interstitial nephritis occurring in a boy ten 
years old. The etiology in this case was obscure excepting 
that he had rheumatism and chorea. Koplik cites a typical 
case and I have encountered it in a colored child nine 
years old that died of a cerebral haemorrhage and in a boy 
eight years old who died of uraemia without premonitory 
symptoms. Guthrie has lately reported seven cases in the 
" Lancet." He considers it not a product of parenchymatous 
atrophy, but an interstitial inflammatory process with round 
cell infiltration of the stroma of the kidney, beginning in the 
cortex and spreading in the form of bands to the centre of 
the organ. 

The urine is pale and abundant, low in specific gravity, 
and contains a small percentage of albumin, which may 
only be present at certain times. Such an albuminuria oc- 
curring several years after an infectious disease, the albumin 
being especially found in the morning urine, together with 
hyaline and granular casts, is a strong evidence of interstitial 
nephritis. 

Dropsy seldom develops, but persistent gastro-intestinal 
symptoms and certain nervous disturbances, such as periodic 
headaches, vertigo, or convulsions, together with high 
arterial tension and hypertrophy of the heart, are indicative 
of contracted kidney, even in the absence of albumin. The 
prognosis depends much upon the compensation and integrity 
of the circulatory system, and the course is more protracted 
than in parenchymatous nephritis. Uraemia or a fatal 
haemorrhage into the brain or other organ of the body usually 
terminates the disease. 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 377 

Treatment. — The diet should be restricted in nitrogenous 
food — not, however, absolutely so, especially when there is 
great exhaustion and anaemia ; its administration must, how- 
ever, be carefully watched and entirely forbidden when 
uraemic symptoms threaten. Milk is the ideal food for these 
cases ; it should hold the most prominent place in the dietary, 
and it can be modified in many ways to vary the monotony 
of its administration. Fresh vegetables, fruit and cereals, 
and vegetable soups made with a shin-bone stripped of the 
meat, or young chicken, are all allowable. There is danger 
of giving too much water and other fluids in these cases, as 
von Noorden points out. The damage done to the heart and 
arteries may be greater than the good accomplished by this 
excessive " flushing of the kidneys." 

The function of the skin should be promoted and the 
cutaneous circulation stimulated by the morning sponge-bath, 
followed by vigorous rubbing. The under-garments must be 
of wool, to protect against any sudden chilling. 

Water should be drank regularly between meals, in moder- 
ation ; such springs as Poland, Bedford and Waukesha, or a 
distilled water, are especially beneficial in keeping up a suffi- 
cient excretion of urinary solids. 

The measures recommended for dropsy and uraemia under 
acute nephritis are equally applicable here. The remedies 
most useful for the nephritis itself are Apis, Arsenicum, 
Aurum mur., Canth., Merc, cor., Phos. and Plumbum. 
These remedies are strictly homoeopathic to the pathological 
process in the kidney, and have proven themselves of great 
clinical value. Aurum and Plumbum are particularly related 
to the interstitial form of nephritis. 

If, in spite of the well-selected remedy, dropsy remains un- 
improved and the flow of urine dangerously scanty, nothing 
will act more favorably than Apocynum cannab. given in ten 
to fifteen minim doses of the decoction (Boericke & Tafel's) 
in a tablespoonful of water. The action of this remedy is 
prompt, and I have never seen bad results from its use. 
25 



378 DISEASES OF CHILDREN. 

The attacks of high arterial tension occurring in intersti- 
tial nephritis are controlled by Glonoin, one minim of the 
second decimal dilution, repeated half-hourly. 

Veratrum viride, ix, will keep up the favorable action of 
the Glonoin, and should be substituted for the latter as soon 
as the urgent symptoms have been controlled. 

The nephritis consequent to chronic suppuration, vertebral 
caries, etc., will call for Asaf., Aurum, Calc. phos., China, 
Ferrum, Hepar, Iodoform, Mezer., Phos., Phos. AC, Sil., 
Sueph. The operation of stripping the kidneys of their cap- 
sule has produced a marked temporary decrease in the elimi- 
nation of albumin, but it has not resulted in regeneration of 
the kidney parenchyma and improvement of the eliminating 
function as much as was hoped it might. 

DIABETES INSIPIDUS. 

Diabetes insipidus is more frequently encountered during 
childhood than saccharine diabetes, but both are rare diseases. 
Of the cases reported in literature about 20 per cent, have oc- 
curred in children under ten years. 

The etiology and pathology are obscure ; heredity, trauma- 
tism to the nervous system and organic brain disease, how- 
ever, seem to bear distinct relationship to some cases, and it 
has occasionally developed after the infectious fevers. 

The pathognomonic symptoms are polyuria and great thirst; 
the urine is pale and limpid, of low specific gravity, and con- 
tains neither sugar nor albumin. With this there are symp- 
toms of impaired digestion, constipation and functional nerv- 
ous disturbances. The onset is usually gradual and the 
course a prolonged and tedious one, either ending in recov- 
ery or in death from exhaustion or some intercurrent affec- 
tion. The prognosis is not altogether unfavorable, especially 
in the young. 

Differential diagnosis rests between diabetes mellitus and 
interstitial nephritis. From the former it is readily distin- 
guished by the low specific gravity of the urine, the absence 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 379 

of sugar, as well as lack of marked and rapid emaciation. 
Interstitial nephritis is associated with arterio-sclerosis, hyper- 
trophy of the heart and characteristic nervous phenomena, 
and repeated careful examinations of the urine seldom fail to 
find albumin and hyaline casts. Hysterical polyuria is emo- 
tional in origin and only a temporary disturbance. 

The remedy which has yielded the most satisfactory re- 
sults in my hands in cases of persistent polyuria, when the 
patient has been obliged to urinate freely every two hours, 
or even more frequently, during the day, and four to six times 
during the night, the urine being pale and limpid, is Natrum 
muriaticum, 6th dilution. Thirst may be a prominent symp- 
tom, together with constipation, etc. 

Ignatia is occasionally useful in highly nervous tempera- 
ments. Goodno has obtained positive results from Strophan- 
thns ix. Hughes recommends Scilla 2x ; Schuessler, Ferrum 
phos. ix. Every case will, however, require individual study, 
from the standpoint of the constitution, temperament and 
general disturbances. 

DIABETES MELLITUS. 

True diabetes is very rare during childhood, and its 
pathology, etiology and symptomatology need no special 
mention here, as it is identical with the same condition in 
adults. The course, however, is more rapid, and it is 
almost invariably fatal. The disease may terminate in a few 
months with diabetic coma ; or if it is a mild case, yielding 
to treatment, it may run for years. A boy, five years old, 
came to my clinic, who, for the past six weeks, had lost flesh, 
was weak and listless and passed large quantities of urine. A 
specimen was immediately examined and found to contain 
sugar. The case was not brought back, but we learned later 
that two weeks after seeing him he had died. At the present 
time I have under my care a girl thirteen years old who has 
had diabetes for two years and although she is passing a large 
amount of sugar, and there is acetone in the urine, still her 
general condition remains good. 



380 DISEASES OF CHILDREN. 

The onset is sudden in the majority of cases, often follow- 
ing upon some acute infectious disease (Stern). 

The pathognomonic symptoms of diabetes mellitus are 
polyuria, voracious appetite and great thirst, with usually 
constipation and indigestion, marked and rapid emaciation, 
dryness of the skin and nervous disturbances, such as formi- 
cation and neuralgia. The urine contains glucose, and its 
specific gravity is high. The more protracted cases fre- 
quently develop cataract. The differential diagnosis has 
been mentioned under diabetes insipidus. 

Treatment. — The first step in the treatment must naturally 
be the selection of a suitable diet. The majority of clinicians 
adhere strictly to the diabetic diet, although quite a number re- 
commend a more liberal mode of feeding. No doubt there are 
cases which thrive just as well, or even better, on a liberal 
diet, but personal observation leads me to believe that they 
are rather the exception than the rule. Goodno recommends 
the employment of a diet absolutely free from carbo- 
hydrates until the glucose disappears from the urine, then 
gradually increasing the dietary and noting the effect of each 
new article upon the urine. This is perhaps the most rational 
way of feeding diabetes, as this method withholds nothing 
excepting what an accurate observation has shown to be 
injurious to the patient. Von Noorden's method of gauging 
the diet in diabetes is the most accurate and scientific of all 
recent contributions to the literature of this subject. It is 
clearly set forth by L,awrence in the N. Amer. Jour, of Horn., 
Jan., 1904. When acetone and diacetic acid are persistently 
present in the urine it becomes imperative to allow the patient 
a certain amount of Carbohydrate. 

Meat, fish, eggs, vegetables not containing much starch, 
fats and oils, gluten bread and milk should constitute the 
diet list as far as possible. Water should be administered 
freely. The very best water for these cases is Allouez, from 
Green Bay, Wisconsin. The results from its employment are 
most gratifying, and Clifford Mitchell {Hahnemannian 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 381 

Monthly y January, 1897) reports several remarkable cures 
from the use of this spring alone. 

Arsen. — Great emaciation and exhaustion ; anaemia ; in- 
tense thirst ; associated nephritis ; complications, such as 
boils, gangrene, cutaneous eruptions. 

Aurnm. — Syphilitic dyscrasia ; profound neurasthenia and 
mental depression. 

Helonias. — Great weakness, with pain and lame feeling in 
back ; numbness and formication in legs and feet ; dejected 
mood. 

Lachesis. — Development of carbuncles during the disease ; 
last stages. 

Lactic acid. — Gastric disturbances predominate {Uranium 
nitr.) ; dryness of tongue ; empty feeling in epigastrium ; 
constipation ; stools hard and black ; sluggish circulation in 
extremities. Administered in the lower dilutions. 

Lye. — This remedy is often indicated by its gastric symp- 
toms, together with the presence of uric acid in the urine 
(Plumbum). Pulmonary phthisis with hectic fever. 

Nux vom. — When the digestive tract is the main seat of 
disturbance ; also neuropathic cases with many characteristic 
nervous phenomena, such as formication in the limbs ; 
irritability ; numbness and paretic condition of the lower ex- 
tremities ; gouty inheritance. 

Nux, Phosphoric acid and Arsenic are perhaps the most fre- 
quently helpful remedies. 

Phos. ac. — Cases of nervous origin. Profuse urination, 
with pain in back and region of kidneys, accompanied by 
great prostration, emaciation and sleeplessness. Rapid- 
growing youths. 

Uranium nitr. — According to Prout, this remedy is espe- 
cially useful when the disease originates in disturbances of 
the digestive tract, in contradistinction to Phosphoric acid, 
which is indicated when it originates in the nervous system. 

Rhus aromatica is a favorite remedy with the Eclectic 
school, and it certainly has a marked control over the elim- 



382 DISEASES OF CHILDREN. 

ination of sugar through the urine. It is particularly indi- 
cated when there is dribbling or incontinence of urine, being 
administered in doses of several drops of the tincture, three 
to four times daily. 

RENAL CALCULI. 

The uric acid diathesis is responsible for the majority of 
cases of calculi in children. These calculi are usually small 
and passed as gravel, inducing the characteristic pains known 
as renal colic. If not passed with the urine, they become the 
nucleus for a vesical calculus. Other varieties of calculus, less 
frequent, however, than the uric acid concretions, are those 
composed of oxalate of lime, carbonate of lime and cystin. 
Phosphatic concretions are rare during childhood, as they re- 
sult from inflammatory conditions of the urinary tract, while 
the others are primarily found in the urine. 

According to Cadge, the prevalence of renal stone in chil- 
dren is due to improper diet and an insufficient quantity of 
milk, prevailing particularly when solid or artificial foods are 
administered in excess. Heredity and prolonged febrile dis- 
turbances seem also to have a strong relationship to the 
etiology. The majority of cases have been met with among 
the poorer classes (Sir Henry Thompson). In the new- 
born uric acid infarctions are normally present in the urine ; 
they are most marked in the second half of the first day and 
on the second day (Morse). No doubt they are derived 
from the nuclein of the leucocytes that are destroyed in the 
blood at this period. 

Symptomatology. — The presence of gravel in the urine 
may be the only sign of any disturbance, unless pain becomes 
a prominent symptom. The child may cry every time it 
urinates, and inspection will reveal uric acid crystals and 
irritation of the urethra. " Occasionally, no doubt, there are 
renal colics quite unrecognizable in our young patients, 
although the urine may guide the treatment if charged with 
uric acid or mixed with blood " (Finlayson, Keating } s 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 383 

Cyclopedia). At times, however, the typical symptoms as 
found in adults will be present. Phimosis may produce 
symptoms similar to those of gravel and this condition must 
be taken into consideration in making a diagnosis. 

The symptoms due to defective elimination of uric acid 
are chiefly referable to the nervous system and digestive 
tract, making the little patient precocious, irritable and 
neurasthenic. Headache and insomnia are common disturb- 
ances. The digestive process is retarded, and catarrhal in- 
flammations in various portions of the alimentary and respi- 
ratory tract frequently develop. For a fuller description of 
this dyscrasia see article upon V Lithsemia." 

Treatment. — In the treatment of the diathesis the diet is of 
the greatest importance. Starchy foods, sugar and meat are 
to be avoided, encouraging the free use of milk, green vege- 
tables and fruit. Poultry, fish and eggs may be allowed 
sparingly. Water should be drank freely between meals, and 
sufficient exercise, together with plenty of sleep, must be ob- 
tained. It used to be held that old meats were most con- 
ducive to the production of an excess of uric acid in the 
blood, but it has been found that the younger meats and 
glandular structure, such as sweetbreads, are the greatest uric 
acid producers on account of their richness in nuclein. The 
older meats, on the other hand, contain less nuclein, but they 
are not as digestible, owing to the larger amount of fibrous 
tissue they contain. 

For the constitutional condition, one of the follow rem- 
edies will usually be indicated : 

Berberis. — Yellow turbid urine, mushy sediment. 

China. — Urine is pale, becoming turbid on standing, with 
yellowish flocculent sediment, or scanty urine with brick-dust 
deposit. 

Lycopodium. — Brick-dust deposit in urine. It is scanty, 
high-colored, and stains the diaper a deep yellow. Whenever 
the child urinates it cries from the burning and smarting pro- 
duced by the irritating urine. 



384 DISEASES OF CHILDREN. 

Nux vom. — Gastric symptoms ; constipation ; insufficient 
exercise and sleep ; gouty inheritance ; painful urging to uri- 
nate ; pain in right kidney, worse lying on the affected side ; 
reddish urine. 

Natr. mur. — Profuse and frequent urination. The urine is 
pale, and deposits a brick-dust sediment. Constipation ; 
emaciation ; anaemia. 

Sepia. — Urine offensive, with greasy pellicle, leaving a 
pink, paint-like deposit in vessel. 

Sulphur. — This remedy is frequently indicated by its gen- 
eral characteristics. 

For the painful symptoms, one of these remedies should be 
considered: Arg. nitr., Aeon., Arsen., Bell., Berb. vulg., 
Canth., Dioscorea, Lye, Nux vom., Pareira brava, Tabacum, 
Uva ursi. The inhalation of an anaesthetic or the adminis- 
tration of a narcotic is justifiable in the presence of uncon- 
trollable, excruciating pain. 

Berberis. — "I wish to sing the praises of Berberis as a gen- 
eral remedy for pains centering in the region of the kidneys, 
radiating thence in every direction, especially down the ure- 
ters." — (Wm. BOERICKE. North Amer. Jour, of Horn., May, 
1898.) 

CYSTITIS. 

While cystitis is not a common affection of childhood, still 
there are certain conditions that frequently lead to its devel- 
opment. Vesical calculus, for example, although net invaria- 
bly setting up a cystitis, is one of its commonest causes. In 
this connection it will be well to study the symptoms of stone 
in the bladder as detailed below, for there are certain devia- 
tions from the symptom-group which is found in adults. The 
acute infections, notably scarlet fever, diphtheria and typhoid 
fever, are at times complicated with acute cystitis, usually as 
a result of infection following retention. The bacillus coli 
communis is credited with being the cause of the majority of 
cases of cystitis, although the typhoid and diphtheria bacillus 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 385 

may act as the exciting agent. Besides these varieties there 
is the tiiberculous cystitis, and in rare instances the gonococcus 
has been known to set up cystitis in children (Bagixsky). 

Retention of urine, either during the course of an infectious 
disease or from phimosis or other congenital narrowing of the 
urinary tract, is a strong predisposing cause. 

Errors in diet leading to oxaluria may be the cause of 
frequent and painful urination, but the condition can hardly 
be termed cystitis. The same is true of litheemia. 

Among the rarer causes are tumors and foreign bodies in 
the bladder. 

Girls are more often affected than boys. 

Symptomatology. — In acute cases there is fever and rest- 
lessness ; tenderness over the bladder ; frequent and painful 
urination, the urine containing mucus, pus, and usually 
blood. 

In the subacute and chronic forms the symptoms are less 
intense and there is generally no fever. Here it becomes 
necessary to determine whether it be a simple cystitis, a 
tuberculous cystitis, or a case of stone in the bladder. Ne- 
phritis must also be excluded. 

Simple cystitis is not associated with pronounced hsematuria 
and seldom assumes a prolonged and chronic course under 
appropriate treatment. The urine contains mucus in abund- 
ance, together with bladder epithelium and pus corpuscles. 
The cystitis can usually be traced back to an acute infectious 
disease or to an attack of retention from phimosis or other 
cause. 

Tuberculous cystitis is associated with much pain, and hem- 
aturia is an early and prominent symptom. The urinary 
sediment is less gelatinous and more flocculent than in simple 
cystitis (Terrilxox). It usually retains its acid reaction. 
By rectal examination enlarged lymphatics may be felt, and 
there may be glandular swelling in the iliac fossa (Ashby 
and Wright.) Lastly, the presence of the tubercle bacillus 
in the urine will render the diagnosis absolute. 



386 DISEASES OF CHILDREN. 

An irritable bladder, the result of some form of irritation 
in the genito-urinary tract, most commonly phimosis, lith- 
semia, or phosphaturia, is recognized by the entire absence of 
any inflammatory condition. 

Stone in the bladder may set up a severe cystitis, but this 
is not an invariable result of calculus. There may be noth- 
ing more than vesical irritability. Stone is most commonly 
of the uric acid variety, its source being the kidney. The 
classical symptoms of stone observed in the adult may be 
wanting, the most prominent symptoms of this condition in 
children being extreme vesical tenesmus often leading to 
prolapsus ani. Any case of prolapsus ani of long standing 
should lead to an examination for stone. 

Treatment. — Rest in bed is imperative in the acute form. 
When the acute symptoms have been controlled, should there 
still remain an excessive amount of mucus and some pus in 
the urine, the bladder should be washed out daily with a two 
per cent, solution of boric acid. All mechanical conditions, 
such as phimosis or calculus, must receive appropriate surgical 
treatment. A liquid diet, consisting mainly of milk and 
water in large quantities, is imperative in acute cases ; chronic 
cases should avoid meat in excess; also stimulants and acids 
excepting the fruit acids. An alkaline water is of great bene- 
fit, while urinary antiseptics are sometimes useful. Boric 
acid, grains one to three, three times daily, and Urotropin in 
the same dosage are the ones to be recommended. Of in- 
ternal remedies, Cantharis is no doubt the most useful. In 
acute febrile cases, Aconite or Belladonna may be indicated. 
In chronic cases, Lycopodium is very important. Other rem- 
edies to be considered are : Apis, Berberis, Hyoscyamus, Ter'e- 
binthina, Uva ursi, acute cases; Chimaphila, Dulcamara, 
Hydrastis, Lycop., Natr. mur., chronic cases ; Arsenicum, 
Arsenic, jod., Lycop., Sulphur, tuberculous cases. 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 387 

ENURESIS. 

Enuresis cannot be said to exist as a pathological condition 
until after the second year, for the child does not learn to 
voluntarily hold back the urine until after the first dentition 
period. A lack of physiological development of the sphinc- 
ter vesicae or an excessive irritability of the bladder are the 
essential features of this neurosis, although reflex irritation 
frequently seems capable of inducing enuresis in many in- 
stances. In the majority of cases, however, both of these 
conditions are operative, and, accordingly, both must be cor- 
rected before a cure can be established. Briick (Der Kinder- 
arzt, Feb., 1900) expresses the belief that the heavy sleep 
natural to children is one of the chief predisposing causes to 
enuresis. It is more common in boys than in girls. 

Enuresis exists primarily in children who are anaemic, 
neurasthenic or otherwise poorly nourished, and especially in 
nervous temperaments, the precocious being perhaps most af- 
flicted, although the idiotic are late in learning to control 
micturition. Symptomatically it may occur in almost any 
organic nervous disease, particularly in epilepsy, where noc- 
turnal enuresis is often the earliest symptom attracting atten- 
tion, the convulsive seizure having been overlooked. 

A highly-acid urine, cystitis and vesical calculus are also 
prominent causes of this affection. 

Among the reflex disturbances capable of exciting enuresis 
must be considered phimosis ; adherent prepuce and clitoris ; 
abnormally small meatus ; adenoid vegetations ; rectal fis- 
sures and polypi ; seat-worms. 

Habit must also be credited often as playing a prominent 
role. 

Symptomatology. — Wetting the bed is the most frequent 
form of enuresis, but in many instances the child is unable to 
control the urine during the day as well as night Rarely is 
it purely diurnal. There is no dribbling, but the mere 
thought of urinating induces contraction of the walls of the 



388 DISEASES OF CHILDREN. 

bladder, the force of which the sphincter is unable to over- 
come. During the night a dream may suggest the idea of 
urinating, with consequent wetting of the bed, or the act may 
occur purely reflexly. In the majority of cases the in- 
voluntary micturition occurs in the first hours of the night — 
a time when sleep is usually most profound. 

The course is variable and depends entirely upon the cause. 
In sound children with enuresis depending purely upon reflex 
irritation a cure follows promptly upon the removal of the 
cause. Again, I have seen prompt cure follow when sys- 
tematic exercise and a cold morning plunge bath was pre- 
scribed, after drugs had failed. In feeble, neurotic or de- 
generate children it may prove most stubborn and protracted. 
Of course, almost any case can be controlled, at least tem- 
porarily, by the use of atropine, but this is not a desirable 
procedure and should only be resorted to when the long-con- 
tinued; bed-wetting threatens to demoralize the child through 
shame and loss of self-control. Enuresis rarely persists after 
puberty. 

Treatment. — When beginning the treatment of a case of 
enuresis the physician should bear in mind that this is only a 
symptom^ the cause of which he must seek to fathom and re- 
move. Anatomical defects must be corrected by surgical 
means, and lithsemia, oxaluria and phosphaturia, seat-worms, 
rectal fissures, etc., must receive their just share of attention 
before the enuresis can be properly treated. 

The nose and throat must be thoroughly inspected and 
pathological conditions here receive appropriate treatment. 
L,et us study the state of the nutrition and decide whether the 
child is getting sufficient food, exercise and fresh air. If the 
child is not too anaemic and the heart is normal a cold plunge 
bath may be taken in the morning. When this might seem 
too severe the sponge-bath may be substituted. 

The bed clothes should not be too warm and fluids should 
be taken in small quantities in the evening. It is a good 
plan to waken the child about the time urinating usually 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 389 

takes place and thus get it away from the habit of doing this 
involuntarily. Elevating the foot of the bed has been useful 
in some cases. From the various specifics so highly praised 
I have not obtained uniform results ; they, too, must suit the 
case in every respect, as well as any other remedy, in order 
to be curative. 

Aeon. — Recommended in cases of neurotic origin ; child 
awakens from sleep in fright ; feverishness, due to seat-worms. 

Bell. — This is the specific, usually employed in the form of 
Atropine. When indicated by its characteristic nervous 
symptoms it frequently relieves in potency. Its action upon 
the involuntary muscle fibre of the badder in large doses is a 
paralyzing one, in this way controlling the over-sensitive 
organ. 

Benzoic acid. — Strong penetrating urine. Dilute Nitro- 
muriatic acid is useful in highly lithsemic cases. 

Caust. — Enuresis during first sleep ; atony of the sphincter 
vesicae. Hughes has often used it with success. 

Cina. — Helminthiasis. 

Equisetum. — This remedy has quite a reputation in enu- 
resis, being employed in drop-doses of the tincture. It seems 
to control the habit very satisfactorily in many instances. 

Ignatia. — Ignatia has given me the best results in those 
nervous, irritable children who are precocious and neuras- 
thenic, and in whom the condition is due to a hyperesthesia 
of the neck of the bladder and urethra. This can be demon- 
strated by the passage of a sound, which induces intense 
burning pain out of all proportion to the usual discomfort ac- 
companying this operation. Curative results were obtained 
by the use of Ignatia alone, although passing cold steel 
sounds is considered highly beneficial, especially in young 
boys who masturbate (POWERS, Surgical Diseases oj Chil- 
dren). For the prostatic irritation induced by this vicious 
habit there is no more useful remedy than Staphisagria. 

Ferrum and Ferrum phos. have proven beneficial in anaemic 
children ; they are recommended for the diurnal variety. 



390 DISEASES OF CHILDREN. 

Sulphur. — " The remedy which, among all others, has 
given me the quickest results is, without any doubt, Sulphur, 
no matter if the children were blonde or brunette, fat or thin, 
etc." (Jahr, Therapeutische Leitfaden). He recommends this" 
remedy to be given first in every case in the absence of strong 
indications for another. In my hands it has only been of 
service when the typical sulphur constitution was present, 
but it is, no doubt, one of our most valuable remedies in enu- 
resis. The child requiring Sulphur is lithaemic or neuras- 
thenic. It is fond of sweets and highly seasoned foods and 
complains of a host of nervous and dyspeptic symptoms too 
numerous to mention. 

Besides these remedies the Calcareas, Lye, Plantago, Puis. 
and Sepia have been recommended. 

VULVOVAGINITIS J GONORRHCEA. 

Vulvovaginitis is a catarrhal inflammation of the mucous 
membrane of the vulva and adjacent parts and in the cases 
encountered in hospital and dispensary practice is most fre- 
quently gonorrhceal in orgin. Anyone who will take the 
trouble to examine the pus from these cases will find to his 
surprise diplococci within the pus cells staining distinctly 
with aniline dyes and decolorizing by Gram's method (the 
gonococcus of Neisser). Koplik (1893) cultivated the organ- 
ism, definitely proving its identity. This has been done since 
repeatedly. 

By no means every case of vulvovaginitis is gonorrhceal, 
however, but the proportion of specific cases is so constant that' 
the subject of gonorrhoea, its complications and its control in 
children, has become one of the most important topics in 
pediatrics in late years. 

Non-specific vulvovaginitis is a simple catarrhal process due 
to lack of cleanliness ; local irritation, such as smegma, seat- 
worms or masturbation ; or it may be but part of a general 
catarrhal condition in scrofulous children. 

There is a form of purulent vulvovaginitis and urethritis 



DISEASES OF THE KIDNEYS AND URINARY TRACT. 391 

affecting both male and female children which is distinctly 
contagious and is due to a diplococcus which does not show, 
however, the staining and cultured peculiarities of the gono- 
coccus (Koplik). It is conceivable that this is a degenerate 
or attenuated form of the gonococcus. 

The spread of vulvovaginitis is surprisingly sure and rapid 
when children are brought into close contact, as in a hospital, 
for example. Every precaution should be taken, therefore, to 
prevent contagion. 

Many children contract the disease from their mothers or 
attendants. It is often difficult to find the original source of 
infection. Rarer modes of transmission are by rape and at- 
tempted sexual intercourse of young boys with other children 
or women. Such cases we occasionally see in the dispensaries. 

The gravest aspect of gonorrhoea is its complications. Sal- 
pingitis and peritonitis have been observed (Marx ; Sanger). 
This leads to death or sterility. It is a rare complication. 
Infection of the eyes — ophthalmia — is constantly to be 
dreaded. 

Arthritis in children is not infrequently gonorrhceal. Holt 
and Kerley have observed that the majority of arthrites that 
were formerly looked upon as being septic are gonorrhceal. 
Kimball (N. Y. Med. Record, Nov. 20, 1903) reports eight 
cases of pyaemia with joint involvements in infants in all of 
which the gonococcus was demonstrated. No primary local 
lesion was present. The majority died during the height of 
the attack. 

One of my cases, an infant three weeks old delivered in 
the Hahnemann Hospital Maternity developed ophthalmia 
three days after birth and a week later successive involve- 
ment of the shoulder, elbow and hip-joints. On one hand 
the second finger became involved in a fusiform swelling 
(dactylitis) and the wrist was also swollen. The temperature 
was continuously elevated, ranging from 101 to 102. 5 ° F. 
Dr. Sappington obtained pus from the joints in which 
he demonstrated gonococci, verified by cultures on ascitic 



392 DISEASES OF CHILDREN. 

fluid and agar. The child was taken home when four weeks 
old and died shortly after from marasmus, after apparent 
improvement in the joint condition. 

Treatment. — In the acute stage the local condition is much 
benefited by irrigation with a warm solution of a non-irritat- 
ing silver preparation. One pint of a i to 500 solution of 
Protorgol or Albargin (I prefer the latter) may be used twice 
daily. The vulva and vagina are most satisfactorily irrigated 
through a small, soft rubber catheter, which may be gradually 
introduced into the vagina as the secretion from the external 
parts is flushed away. The vulva is then dried and dusted over 
with Boric acid. 

In the subacute and chronic stage Permanganate of Potash, 
1-1,000, may be used every day or two in a similar manner, 
followed by the dusting powder. Sometimes the dry treat- 
ment will give better results than douches. 

In the early stages Cannabis Indica is indicated, or Can- 
tharis when there is dysuria. When the discharge becomes 
profuse and yellow Pulsatilla is the most useful remedy. In 
chronic cases, Sulphur or Sepia. 

Non-specific vulvovaginitis usually calls for Calc. card. 



CHAPTER XIV. 

DISEASES OF THE SKIN. 

Certain peculiarities characterize the condition of the skin in 
the new-born. At birth the entire body is covered with a waxy 
secretion, the vernix caseosa, which has served as a protective 
layer to the skin during intra-uterine life. The color is a 
deep red, owing to the vigorous surface circulation, and this 
condition persists for about a month. Usually desquamation 
of the epidermis, visible on close inspection, takes place dur- 
ing the second week. Jaundice, occurring on the third or 
fourth day, was found in 80 per cent, of all infants observed 
by Runge. 

The skin of the infant is exceedingly tender and susceptible 
to all forms of local irritation, as well as being readily disturbed 
in its function and structure by abnormal conditions. Sweat- 
ing is rare in infants, normally not noticed before the fourth 
month, and when persistent it becomes a strong presumptive 
sign of rickets. The use of irritating soaps, excessive bath- 
ing, and, on the other hand, uncleanliness, are important 
etiological factors in the skin diseases of childhood, next to 
which improper feeding ranks. Syphilis and parasites are 
other prominent causes. 

Almost any of the skin diseases of adults may be encount- 
ered in children, but the ones here described are the most 
common and important. 

In all instances the cause of the disease, if possible, must 
be removed. Diseases due entirely to local irritation and 
those responsible for their existence to parasites rarely de- 
mand anything but local treatment, while those dependent 
upon a hereditary taint or constitutional dyscrasia must be 
eradicated by the administration of the well-selected homoeo- 
pathic remedy. 
26 



394 DISEASES OF CHILDREN. 

inflammations: eczema; tetter. 

Definition. — Eczema is an inflammatory, acnte or chronic 
non-contagious disease of the skin, in the beginning present- 
ing erythema, papules, vesicles or pustules, often in combina- 
tion, associated with a varying degree of infiltration, burning 
and itching, and ending in serous and puriform degeneration. 
The formation of scales and crusts is a usual sequel. 

Symptomatology. — Any or all varieties of eczema may be 
present in infancy and childhood. Eczema erythematosum 
appears primarily as a reddened, mottled condition, without 
exudation. Later the involved surfaces may become excori- 
ated and throw off a few scales of epidermis. In children it 
is seen most frequently about the genitals, the buttocks, and 
between the thighs, as a result of maceration of the epidermis. 
This form of eczema, or intertrigo, as it is frequently called, 
is a common and troublesome condition showing strong ten- 
dency to relapse when the infant is not cared for most tenderly. 

Eczema papillosum. — This variety presents papules of vary- 
ing size, surrounded by an erythematous or empurpled base 
and surmounted by a layer of thin scales. From incessant 
scratching the summit of these lesions becomes abraded and 
excretes a sticky serum, producing an eczema vesiculosum. 
The trunk and flexor surfaces of the limb are usually involved. 
This variety is slow to respond to treatment. 

Eczema vesiculosum. — Vesicles, usually minute, character- 
ize this type. Their apices are rilled with a yellowish, sticky 
fluid. In most cases they rupture and coalesce, forming 
crusts. The lesions are usually situated upon the face, neck 
and scalp, and are attended with severe burning and itching. 
The vesicular variety is common to infants. 

Eczema pustulosum. — In some cases, either because of a 
peculiarly favorable soil or by reason of the intensity of the 
inflammatory process, pustules rapidly develop upon a group 
of papulo-vesicular lesions. Indeed, it is not uncommon to 
find a lesion commencing as an erythema and running 



DISEASES OF THE SKIN. 395 

through all of the stages to pus formation. Eczema pustu- 
losum usually results from a distinct pyogenic infection, 
traceable to scratching with dirty finger-nails. Eczema nibrum 
is not a distinct variety. It is a name applied to a condition 
presenting a complexity of symptoms, including erythema, 
papules, vesicles, pustules and scales. The parts involved 
are reddened, infiltrated, excoriated, and frequently covered 
with crusts. It is usually found about the bends of joints, 
and is attended with marked discomfort. 

Eczema squamosum. — This is a chronic variety, and usually 
results from an attack of erythematous or papular eczema. 
Typical cases show thickened and infiltrated areas, situated 
upon the face and back of the neck. Sometimes the lesions 
are widely scattered. 

Etiology. — Of late, dermatologists have attempted to estab- 
lish the parasitic theory of eczema, but have failed because 
of inability to discover a specific micro-organism. Scabies 
and pediculosis are often responsible for an eczema, the con- 
dition resulting from the irritation and scratching these para- 
sites induce. The disease in infants may be traced directly 
to the action of local causes ; particularly is this true with 
the newly-born, who are subjected to vigorous baths and en- 
ergetically anointed with irritating lard and afterwards 
tightly enveloped in woolen garments — procedures likely to 
irritate a tender and delicate skin. The irritating discharges 
accompanying the diarrhoea of infancy frequently produce a 
local dermatitis, which is quickly converted into a weeping 
eczema. A tight or elongated foreskin and catarrhal inflam- 
mation of the vulvo-vaginal glands are frequently responsible 
for eczema in these parts. The too liberal application of 
water, the use of impure soaps and toilet articles, tight and 
heavy clothing, may provoke an attack. Vaccination plays 
a role in the causation of eczema. From a clinical stand- 
point, dentition and eczema seem to be closely related ; and, 
although it is difficult to understand this, yet attacks are ag- 
gravated by the eruption of a tooth, subside shortly after- 



396 DISEASES OF CHILDREN. 

wards, and occur upon the eruption of others. Occasionally 
too liberal indulgence in sweets will excite an attack. The 
fundamental cause of eczema of infants and children may be 
traced to a constitutional diathesis, usually hereditary, some- 
times acquired. Kczematous parents often beget eczematous 
children. Although eczema occurs among the children of 
the rich, it is seen most frequently amongst the poor and illy- 
nourished, particularly amongst light-haired children, who 
show a tendency toward catarrhal affections of the upper air- 
passages (the so-called "scrofulous" diathesis). Eczema is 
occasionally associated with impetigo contagiosa and some of 
the other pustular dermatoses ; it may follow scarlatina and 
varicella. 

An attack may assume an acute, subacute or chronic form ; 
the majority of cases are subacute. A varying degree of burn- 
ing and tingling accompanies all phases of the disease. Acute 
infantile eczema is accompanied by moderate fever; the skin 
of the affected region assumes a reddened hue, and is attended 
by catarrhal exudation. Itching and burning are prominent 
symptoms. Acute infantile eczema usually commences upon 
the scalp, a favorable soil being furnished by the sebacious 
secretions of this region. This, together with the gummy 
contents of the vesicles, forms dirty, grayish-yellowish crusts 
(crusta lactea). 

Through infection or the association of head lice this con- 
dition may become most repulsive and malodorous. In ad- 
vanced cases the glands about the ears and neck become in- 
volved, and not infrequently suppurate. Furunculosis of the 
scalp, face and neck is by no means a rare complication. 
Itching, scratching and inflammation reduce the sufferer to a 
condition often grave. 

In scrofulous children a pustular condition of the eyebrows 
results in subsequent crusting and destruction of the hair-fol- 
licles; frequently catarrhal conjunctivitis is present The 
mucous membrane of the nose becomes involved. At first a 
thin, watery, later a thick, purulent discharge occurs, which 



DISEASES OF THE SKIN. 397 

forms pustules about the lips and angles of the mouth, re- 
sembling very much the lesions of impetigo contagiosa. 
Eczema genitalium frequently complicates the condition, 
presenting an erythematous variety, which may assume a 
vesicular form and invade the spaces between the thighs. 
The perinaeum, anus, penis, scrotum and labia may become 
affected. Under such circumstances the parts assume a scar- 
let hue, becoming swollen, infiltrated and raw ; vesicles pre- 
dominate. 

The chronic eczemas of infancy and childhood are confined 
mostly to the scalp, face, and naso-labial furrows, rarely to 
the prepuce and anus. A chronic eczema capitis is usually 
confined to a small area about the occiput. Here papulo- 
squamous lesions predominate; sometimes a pustular type is 
found, for which parasiticism is largely responsible. Chronic 
eczema of the nose and angles of the mouth present fissures, 
crusts and shallow ulcers. A similar condition is seen in 
chronic eczemas about the genitals and anus. 

Pathology. — In acute eczema the pathological changes may 
be diffuse or circumscribed. They are primarily situated in 
the papillary portion of the derma, although they may later 
descend as deep as the fatty layer. They consist of conges- 
tion of the blood and lymph vessels, causing a serous exudate, 
which gives rise to infiltration and induration of the skin. 
This exudate may destroy the rete cells ; the formation of 
vesicles or bullae may be entirely absent, and the exudative 
inflammation result only in the destruction of the epidermis. 
In chronic eczema the inflammatory changes are most 
marked about the blood-vessels in the derma ; the papillae be- 
come hypertrophied ; proliferation of connective-tissue cells 
takes place ; the subcutaneous tissues may become infiltrated 
and thickening result. 

Diagnosis. — Certain characteristic symptoms are invariably 
present in eczema ; burning and itching are peculiar to 
eczematous eruptions, and the skin is usually infiltrated. 
Some discharge may usually be seen ; it may be colorless or 



398 DISEASES OF CHILDREN. 

stain the clothing. Since eczema simulates so many diseases 
of the skin, it will be necessary to point out a few diseases 
for which it may be mistaken. 

Erysipelas is an acute inflammation, involving the deeper 
layers of the skin. It commences from a single focus and 
spreads rapidly, while eczema starts from a larger area. 
There is more fever in erysipelas, and, as a rule, no discharge. 
Erysipelas is rare in infancy, excepting in the new-born, as a 
result of septic infection (see u Diseases of the New-Born," 

P- IX 5)- 

Psoriasis is rarely seen in infants and very young children. 

A psoriatic condition of the scalp may suggest a squamous 
eczema of that region. The patch of psoriasis, however, is 
sharply defined, and the scales are abundant, large and 
silvery. Psoriasis is always dry, while eczema usually pre- 
sents some degree of moisture. Psoriasis selects the extensor 
and eczema the flexor surfaces of the limbs. 

Urticaria may be mistaken for a papular eczema, but the 
lesions of urticaria are wheals ; the disease usually follows 
acute indigestion, and is of short duration. There is, how- 
ever, a form of urticaria common in children, described as 
vesicular urticaria. Here small papules and vesicles develop 
over the body generally, especially on the extremities, and 
they are more persistent than the ordinary form of urticaria. 
They are, however, discreet lesions and tend to spontaneous 
cure. 

Papular eczema presents certain features peculiar to lichen 
ruber planus ; both eruptions itch ; both present papules. 
The lichen papule, however, runs a chronic course, does not 
change its identity, and always leaves a certain amount of 
pigmentation behind. 

Syphilis. — In all cases where the slightest possibility exists 
of a skin eruption being syphilitic we must inquire most 
thoroughly into the previous history of the case as to 
snuffles ; persisting hoarseness ; papules, pustules and ulcerat- 
ing lesions about the anus and genitals. The mother's history 



DISEASES OF THE SKIN. 399 

must also be inquired into, especially as to miscarriages. 
Usually syphilitic eruptions are characteristic— their color, 
distribution and polymorphism being pathognomonic. In 
chronic relapsing syphilides, for instance, the circinate 
papular syphiloderm, the diagnosis is not always easily made, 
but their location (forehead), circular outline and distinct 
scaliness with absence of itching should serve to differentiate 
them from eczema. 

The papules of syphilis do not itch and are usually grouped. 
An eczema of the scalp may resemble syphilis of that region, 
particularly where the lesions are of a pustular character. The 
syphilitic process, however, is more extensive ; the disease 
makes inroads upon the scalp and ulceration is somewhat ex- 
tensive ; rupial crusts are usually present. As a last form of 
evidence, the therapeutic test may be applied. 

The points of resemblance which impetigo contagiosa, 
pediculosis capitis and scabies bear to eczema are pointed out 
under these special subjects. 

Prognosis. — The course of an eczema depends upon so 
many circumstances that it is difficult to accurately foretell 
its outcome. As a rule, it runs a chronic course — age, the 
location affected, the exciting causes, heredity and constitu- 
tional predisposition are factors which must be considered. In 
the majority of cases the existing eruption can be controlled. 
Proper hygienic surroundings and cleanliness will cure many 
of the simpler types, while those dependent on a scrofulous 
taint are exceedingly rebellious to treatment. Acute eczema 
capitis, if uncomplicated by parasiticism, may, by proper 
treatment, be quickly controlled. Eczema of the nose is slow 
to respond to treatment. The eczema of the genitals and 
anus are peculiarly hard to control, while the squamous and 
papular types often persist for years. 

Treatment. — It would be impossible to decide in a general 
way the treatment of eczema in infants and children. Each 
case, each type and each variety must be isolated and treated 
as a distinct affection. An interna) remedy given for an ec- 



400 DISEASES OF CHILDREN. 

zema of the scalp, caused by pediculi or other parasites, 
would be a waste of time and labor. On the other hand, an 
eczema caused by a psoric taint will never yield permanently 
to anything but a constitutional remedy. 

Piffard (Morrow's System) is a firm believer in the efficacy 
of internal medication in eczema and recommends as the 
most useful drugs Arsenic, the Sulphide of Lime (Hepar 
sulph. calc.) and Viola tricolor. The indications given are 
mainly those upon which we, as homceopathists, base our 
prescriptions. 

In every case the cause must be sought for, and, if possible, 
removed. Its effects may then be rationally eradicated. The 
question should be asked : " Is this condition due to a local 
or constitutional cause, or are both agents responsible ? " 
Again, there are regional eczemas which demand peculiar 
measures for their relief. An inquiry into the causes of the 
vast majority of cases occurring in infants elicits a history of 
a psoric taint. Internal medication is usually alone indicated. 
In those cases arising from stomach or intestinal derange- 
ment, caused by an unsuitable food or overfeeding, a proper 
diet must be prescribed, which, in many cases combined with 
an internal remedy, will effect a cure. 

If the infant be a suckling, the mother's milk should be 
analyzed and if the fat or proteid percentage be too high, her 
diet must be so regulated as to correct this fault (see Chapter 
on Infant Feeding). The same applies to artificially fed in- 
fants, in whom the diet must be carefully regulated and the 
percentages of proximate principles in the food made to con- 
form with the state of the digestion and nutrition. In older 
children the usual dietetic error is eating too much starchy 
food and this should be prohibited. Water is to be given 
freely and constipation carefully guarded against. 

The local treatment will depend solely on the type present. 
In every instance, however, we must first decide: " Does this 
eruption demand a stimulant or a sedative ? " Usually acute 
cases demand sedatives, while chronic ones call for stimulants. 



DISEASES OF THE SKIX. 401 

Acute eczema erythematosum is usually controlled by the fol- 
lowing simple dusting powder : 

& Pulv. artiyli, ^vj. 

Zinci. oxidi, ..... ^iss. 

Pulv. carnphorae, 3ss. 

This should be applied to the parts several times daily. It 
is particularly serviceable in controlling the itching. Where 
the genitals become affected, Subnitrate of Bismuth, alone or 
combined with Starch, Talcum or Lycopodium powder, may be 
applied with beneficial results. 

The parts should not be bathed in water, but should be 
mopped with a soft woolen rag and bathed with pure olive oil. 
After this any of the above powders may be used, and a thin 
layer of linen placed between the thighs. The internal rem- 
edies best suited for such cases are Aconite, Bellado7ina and 
Mercurius. Pulsatilla should be given to those cases affected 
by gastric derangement. 

Vesicular eczema is usually found as a subacute or chronic 
condition. Frequently pediculi are present, especially when 
the scalp is invaded, and they should be exterminated 
promptly. Scales and crusts may be removed by soaking 
thoroughly in olive oil. These must be entirely removed 
before a cure may be hoped for ; after which a mild antiseptic 
powder should be used several times daily {Boric acid diluted 
with two parts Starch or Zinc oxid.). Intense itching is very 
frequently controlled by the use of a very weak solution of 
Carbolic acid, five drops to the half-ounce of water. In- 
ternally, a remedy of most positive value in the acute vesicu- 
lar stage is Rhus tox.; its proving shows a vesicular eruption, 
attended with itching, burning and tingling. 

The pustular stage demands Hepar ; later, when the pus- 
tules rupture and throw out a thick yellow fluid, which 
quickly dries and forms crusts, Graphites will be needed ; and 
occasionally, where these symptoms are present and the 
glands of the neck become involved, Sulphur may be advan- 
tageously employed. Frequently, in marasmatic children, 



402 DISEASES OF CHILDREN. 

acute eczema capitis assumes a chronic type ; the lesions are 
squamous, surrounded by an inflammatory base ; the hair is 
dry, lustreless and brittle; the scalp bleeds easily; here Sulphur 
and Arsenicum meet the conditions, while Calcarea carbonica 
is indicated in pale, fat, flabby and pot-bellied children. Oc- 
casionally local remedies are of value, but not nearly as much 
so as in the acute variety. The main indication for local 
treatment is to keep the parts absolutely clean. As plain 
water irritates, a two per cent, solution of Boric acid may be 
used. Should a stimulating application be necessary to 
hasten the cure, a five per cent, ointment of Ichthyol may be 
used. 

Acute vesicular eczema of the face calls for Rhus tox.; 
Apis is indicated if much oedema and erythema are present ; 
Graphites, where the condition becomes chronic. The itch- 
ing in these cases is sometimes intolerable and makes it neces- 
sary to apply a mask of soft muslin with a layer of Zinc oint- 
ment and Lanolin, equal parts, as a protective. The child's 
hands should be encased in mittens ; often it is necessary to 
restrain the arms entirely by pinning them to the sides of the 
body with a sheet wrapped around the body. The best anti- 
pruritic washes are Boric acid, Resorcin and Carbolic acid, 
one to two per cent, solutions of each. 

Eczema of the eyes and of the border of the lids should be 
treated by washing with a saturated solution of Boric acid. 
This dissolves the crusts, and is beneficial to the accompany- 
ing conjunctivitis. This variety occurs in badly-nourished, 
scrofulous children, and calls for the employment of the fol- 
lowing remedies : Graphites, Sulphur, Calcarea, 

One of the most obstinate forms in infants is eczema of the 
genitals and surrounding structures ; it may assume any 
clinical variety. It is usually acute, but may be chronic. 
The surface is raw, and usually exudes a sticky fluid ; the 
genitals become swollen. The inflammation is best combated 
by protecting the skin from the contact of the urine and 
faeces with Calendula cerate. In some cases a cerate is not 



DISEASES OF THE SKIN. 403 

well borne and a dusting powder will act better {Boric acid, 
Zinc oxide and starch, equal parts). Internally, Aconite, 
Arnica, Bryonia, Rhus tox. and Graphites are indicated. 
The subacute types demand a recognition of their cause and 
prompt removal ; in some cases a long foreskin, by causing 
frequent urination, may cause an eczema. Here, after the 
control of the acute symptoms, circumcision is demanded. 
In most cases it must be remembered that diet and hygiene 
will do much toward a cure. 

ERYTHEMA. 

Erythema may be defined as a redness of the skin which 
disappears temporarily upon pressure. Clinically two groups 
are recognized, erythema simplex and erythema exudativum. 
Erythema simplex presents a number of types, among which 
are erythema traumaticum, erythema caloricum, erythema 
venenatum and erythema intertrigo, and the different forms 
of symptomatic erythema, all arising from various causes. 

Erythema simplex is characterized by an eruption of red- 
dish macules of varying size, which disappear upon pressure. 
The causes may be internal and external, the condition aris- 
ing from friction, brought about by wearing tight clothing, 
or from the action of an external irritant. Extremes of tem- 
perature are responsible, and, in some cases, reflex vaso-motor 
irritation, or the ingestion of certain articles of food or drink. 

A more diffuse erythematous rash not infrequently occurs 
during attacks of indigestion as a result of auto-intoxication. 
An erythema of wide distribution may also precede the ap- 
pearance of the papular rash in small-pox or it may accom- 
pany some of the non-eruptive infectious diseases (typhoid 
fever, diphtheria, tonsillitis). The same may be observed 
after vaccination. Any portion of the surface of the body 
may be invaded. The lesions may be widely scattered- 
Fresh crops are usually bright red, fading as they become 
older. Occasionally a slight degree of pigmentation may re- 
main. Itching, burning and tingling, and, in some cases, 
more or less elevation of temperature may be present. 



404 DISEASES OF CHILDREN. 

Erythema traumaticum. — This results from external irrita- 
tion, and, like the former variety, is also due to wearing too 
tight clothing, and may be produced by too vigorous friction 
after the bath. It rapidly subsides after the removal of the 
exciting cause, but may, in some cases, result in acute 
eczema. 

Erythema caloricum results from the action of extremes of 
temperature ; very low temperature or the application of ice 
may produce a diffuse redness which, if continued, may cause, 
a dermatitis ; high temperature, particularly exposure to the 
sun's rays, will cause an erythema which may be brief, or 
which, in severe cases, may terminate in a vesicular eruption. 

Erythema venenatum may be traced to the application of 
certain irritating substances, such as mustard, pepper, turpen- 
tine and ammonia. 

Erythema intertrigo is a redness of the skin at points where 
natural folds come in contact, as the neck, armpits and thighs. 
It is common to infants possessing a delicate skin, and, un- 
less promptly recognized and quickly eradicated, may termi- 
nate in an eczema madidans. Usually there is burning, itch- 
ing and tingling, and a certain amount of exudation. 

Erythema scarlatinoides. — The clinical importance of this 
form of erythema rests upon its close resemblance to scarlet 
fever. Although the majority of cases are mild and evanes- 
cent in character, still there are such in which the entire body 
is covered with rash in association with fever and grave con- 
stitutional symptoms. 

The etiology is most frequently to be found in some form 
of toxaemia ; the commonest source of this is the intestinal 
tract. Eating certain food (shell-fish) or tainted meat may 
give rise to an attack. It is sometimes associated with cer- 
tain infectious diseases and with sepsis. Mercury and Iodo- 
form have also produced similar symptoms. 

The eruption usually appears suddenly, although it may be 
preceded by headache, malaise and fever. The lesions are 
mostly confined to the face, neck, trunk and extremities. 



DISEASES OF THE SKIN. 405 

They are macules or papules of a bright-red color, which gen- 
erally coalesce. It may be difficult to differentiate this va- 
riety from scarlatina, particularly during the first twenty-four 
hours. Usually, however, the eruption quickly fades, leav- 
ing none of the grave symptoms attending scarlet fever. 
Burning and itching may be annoying symptoms. Desqua- 
mation is marked in most cases and recurrences are common. 

The diagnosis from scarlatina rests upon the absence of ex- 
posure to contagion ; the less general distribution of the rash 
and absence of strawberry tongue, sore throat and adenopathy; 
absence of albuminuria. 

Erythema medicamentosa. — This type, like the foregoing, 
usually follows the ingestion of drugs. The eruption is 
macular, and in some instances papulo-vesicular, and even 
pustular. Rarely it may be scarlatiniform in character. The 
eruption is scattered over the head, trunk and limbs, and dis- 
appears upon the removal of the exciting cause. 

Treatment. — Erythema simplex is readily controlled. All 
sources of local irritation must be removed and the diet 
strictly supervised. Internally Nux vomica, Pulsatilla, Hepar, 
Ipecac and Bryonia may be indicated. Local irritation may 
be subdued by dusting powders, and if itching is severe a 
bran-bath will be of service. Erythema intertrigo, if not 
promptly controlled, may result in a very acute eczema. Ab- 
solute cleanliness must be observed and all irritants removed. 
After thoroughly bathing, the parts should be dried with a 
soft towel and freely dusted with equal parts of Starch, Zinc 
oxide and Boric acid. Internally Aconite and Belladonna 
may be administered very early in an attack ; persistent dif- 
fuse redness is relieved by Mercurius, and where vesicles form 
Rhus tox. should be given. 

FURUNCULOSIS J BOILS. 

A furunculus, or boil, is an acute, deep-seated, circumscribed 
inflammation originating in a hair follicle or sebaceous gland 
and terminating in necrosis of these structures and surround- 



406 DISEASES OF CHILDREN. 

ing connective tissue. The cause is infection with the 
staphylococcus pyogenes aureus. 

Symptomatology. — Slight itching and burning, associated 
with a moderate degree of localized infiltration, marks the 
site of a coming "boil." Within a day or two a conical pap- 
ulo-vesicle appears, which later becomes filled with pus. This 
pustule is surrounded by a markedly infiltrated base, and 
there is considerable elevation of the skin. Where the deeper 
structures are involved, the skin becomes thinned and as- 
sumes a bluish hue. Within a few days the tumor may have 
attained a considerable size. Intense throbbing pain, made 
worse by motion, adds greatly to the patient's discomfort. 
Central coagulation necrosis quickly takes place, resulting 
in the formation of a " core," or what is more common 
in children, a small localized abscess. After an opening is 
formed the pain and fever rapidly abate, and the opening 
quickly fills up with granulations. Deposits of pigment may 
persist for some time. Successive crops appear from time to 
time, extending over a period of months. This condition is 
termed furunculosis, for which a constitutional cause is fre- 
quently responsible. Boils are usually seen upon the neck, 
back and nates. 

Furunculosis frequently accompanies and often follows an 
attack of scabies or pediculosis. This will be readily under- 
stood by recognizing how irritated and inflamed the skin be- 
comes as a result of the incessant scratching accompanying 
these parasitic diseases, thus inviting the entrance of pyogenic 
organisms. Improper and tight clothing, irritating soaps, 
poultices, and the too lavish use of strong antiseptic lotions 
may be contributing factors ; and also, it must not be for- 
gotten that this condition is frequently associated with maras- 
mus, or may follow any of the infectious diseases of infancy 
or childhood. 

The presence upon their favorite sites of one or several 
painful conical elevations that suppurate and express a " core " 
will establish the diagnosis of furuncle. A boil is frequently 



DISEASES OF THE SKIN. 407 

mistaken for a "carbuncle." The latter condition, however, 
is serious. Chill and elevated temperature are early symp- 
toms. The skin is hard, and is not freely movable ; local in- 
filtration is pronounced. Several pustules appear which in- 
dicate sites of resulting necrosis. Fortunately carbuncle is 
rarely seen in infancy and childhood. 

Treatment. — Without a doubt the most effective treatment 
is incision, followed by the application of a wet compress of 
a weak solution of Bichloride of Mercury. Internal medica- 
tion is always indicated. 

Hepar sulph. calc. is an ideal drug, not only for this condi- 
tion, but also for all pustular dermatoses. Sulphur is fre- 
quently given with brilliant results. Silicea is especially 
indicated in those cases which tend toward furunculosis. 
The early administration of Belladonna, and occasionally of 
Aconite, will surely minimize pain, and may abort an attack. 
It must be remembered that poor hygiene, uncleanly and 
unsanitary surroundings and improper food, play a most 
important role in the production of pustular diseases ; where 
practicable, these conditions must be corrected. 

IMPETIGO. 

Although very few cases of non-contagious impetigo have 
been observed, yet because of the claims made by Duhring 
( u Cutaneous Medicine "), Stell wagon (" A System of Genito- 
urinary Diseases, Syphilology and Dermatology "), and 
Hardaway (" An American Text-Book of Genito-Urinary 
Diseases, Syphilis and Diseases of the Skin "), dermatologists 
accept a simple non-contagious type of impetigo. 

Definition. — Impetigo is an acute non-contagious dermatitis, 
characterized by the formation of pustules. 

Symptomatology. — This condition is recognized by the 
presence, chiefly upon the face and extremities, of a varying 
number of pustules about the size of a pea. These lesions, 
which appear at times during the course of the disease, are 
discrete, each being surrounded by an inflammatory base. 



408 DISEASES OF CHILDREN. 

They are well distended with a straw-colored fluid, which 
ends in crust-formation without rupture or umbilication. 
Scars never result. Itching and burning may be an annoy- 
ing feature. 

Etiology. — Very nearly all cases occur during infancy and 
early childhood. It is a local infection, for which the staphylo- 
coccus is responsible. 

Diagnosis. — Impetigo simplex resembles closely impetigo 
contagiosa, and in atypical cases a differential diagnosis is 
beset with difficulties. The contagious variety is recognized 
by lesions of a vesico-pustular character. The lesions of im- 
petigo simplex are invariably pustules. Umbilication is seen 
only in the contagious type. 

Prognosis. — This disease is an acute, self-limited process. 

Treatment. — Removal of the cause by proper observance 
of cleanliness will produce a prompt cure. 

IMPETIGO CONTAGIOSA. 

Definition. — Impetigo contagiosa is an acute contagious 
dermatitis, characteiized by the formation of superficial, cir- 
cular or oval vesico-pustules or blebs, which rapidly form yel- 
lowish crusts. 

Symptomatology. — Except in isolated cases, occurring in 
infants, no constitutional symptoms precede or accompany an 
attack. When present, however, they give rise to submaxil- 
lary and pre-aural adenopathy, together with moderate fever. 
The lesions are usually seen upon the face and hands. Where 
the fingers become involved the lesions are situated about the 
tissues surrounding the nails. Exceptionally, lesions are 
found on the trunks and extremities. 

The lesions at first are minute vesicles, later increasing in 
diameter, becoming vesico-pustules. Their contents are sero- 
purulent. Desiccation rapidly occurs, leaving brownish spots, 
which soon disappear. The attack lasts about a w r eek, fresh 
crops appearing daily. Occasionally lesions rupture and 
coalesce, giving a honeycomb appearance to the group ; under 
such conditions itching is a prominent feature. 



DISEASES OF THE SKIN. 409 

Etiology. — Impetigo contagiosa is due to filth, and is rarely 
seen except in dispensary practice or among those who are 
improperly cared for. The disease is very contagious. Adults, 
however, are rarely attacked. Authorities trace the disease 
to the presence of the staphylococcus aureus et albus.- 

Diagnosis. — Impetigo contagiosa may be mistaken for im- 
petigo simplex, varicella, the pustular type of eczema, ec- 
thyma, and pemphigus. The features which distinguish the 
simple and contagious types have been mentioned while dis- 
cussing the former variety. 

From varicella it may be differentiated by the presence of 
lesions of a vesicular or bullous character, which appear in 
crops, and which in some instances leave cicatrices. Varicella 
is occasionally accompanied with grave constitutional symp- 
toms. Pustular eczema may suggest impetigo simplex, al- 
though an eczema invariably produces more infiltration and 
more subjective symptoms. In eczema the lesions, although 
pustular, are deeper, and surrounded by an inflammatory 
areola. The lesions are found upon the legs, regions rarely 
attacked in impetigo contagiosa. Ecthyma is a disease of adult 
life. 

Pemphigus is rarely met with in infants and children. 
The lesions are blebs. Constitutional symptoms are present. 

Prognosis. — Under appropriate treatment a rapid recovery 
may be looked for. 

Treatment. — Warm baths should be given morning and 
evening. Crusts, if adherent, may be removed by soaking 
with olive oil. A mild antiseptic local application, such as 
the ammoniated mercury, ten grains to the ounce of vaseline, 
will cure the majority of cases promptly. Hepar sulpJi. calc. 
may be required to help eradicate the condition. 

URTICARIA ; HIVES. 

Urticaria is -an inflammatory cutaneous affection character- 
ized by the appearance of evanescent pinkish elevations 
( wheals; which are accompanied by considerable itching 
and other sensory disturbances. 
27 



410 DISEASES OF CHILDREN. 

Symptomatology. — The lesion of urticaria is a wheal. 
This begins as a red, slightly elevated spot which enlarges, 
the centre becoming paler in color. In shape it is round or 
oval, frequently changing its size and locality, appearing from 
time to time upon different portions of the body. The lesions 
are particularly evanescent ; they may last a few hours or but 
a few minutes, leaving behind no trace of their former pres- 
ence. Rarely they persist for days ; occasionally they coal- 
esce and attain considerable dimensions. Their favorite seats 
are the extremities and buttocks, although they may appear 
on any portion of the skin or mucous membrane. Their out- 
break is invariably attended with intolerable burning and 
itching, and a slight degree of fever. An attack may be 
acute or chronic. The acute attack is usually attended with 
gastric derangement, headache and slight fever. The erup- 
tion appears and disappears quickly, leaving no trace save a 
few scratch -marks, resulting from the itching. The chronic 
type may last for weeks or months. 

Urticaria papulosa is a skin affection very common in 
childhood. It is characterized by the appearance of small, 
discrete, round papules— often beginning as a wheal, but per- 
sisting as an itchy eruption. They are mostly confined to 
the extremities. Another form frequent in childhood is 
urticaria pigmentosa, in which a pigmented spot persists 
after the disappearance of the wheal. 

Etiology. — Hives arise from causes that are both internal 
and external. Certain seasons are, in a measure, responsible 
for their outbreak ; they are especially apt to appear in the 
spring and fall. Occasionally they accompany attacks of ec- 
zema and pemphigus. The majority of cases occurring in 
children may be traced directly to some gastro-intestinal de- 
rangement. Constipation, diarrhoea, worms, and acute or 
chronic indigestion may occasionally be responsible. Im- 
proper clothing, low or high temperature, and the bites 
or sting of insects may be exciting causes. 

Diagnosis. — The character of the wheals, their evanescence 



DISEASES OF THE SKIN. 411 

and their arrangement, associated with intolerable itching 
and tingling, are sufficient to establish the diagnosis. The 
eruption may be mistaken for eczema papillosum and pemphi- 
gus. Eczema papillosum, however, presents lesions of a 
papular type, which persist for a longer period. In pemphi- 
gus the lesions are bullae. Moreover, pemphigus is a rare 
disease in childhood. There is usually marked constitutional 
disturbance in pemphigus. 

Prognosis. — The prognosis is favorable in the active 
variety. Removal of the exciting cause, usually a gastro- 
intestinal derangement, will effect a cure. In the chronic 
form the tendency to relapses must always be borne in mind. 

Treatment. — The treatment of urticaria is simple. Ar- 
ticles of diet which disagree must be interdicted. Constipa- 
tion or diarrhoea, if present, must be corrected. During an 
attack the diet must be of the plainest kind Locally it may 
become necessary to allay itching by applying a weak solu- 
tion of Carbolic acid, one-half of a drachm to eight ounces of 
water, or hot water to which has been added a little vinegar. 

Aconite may be administered early in an attack to control 
the fever, thirst and restlessness. 

Urtica urens is indicated when itching, burning and ting- 
ling are prominent symptoms. It is indeed almost a specific. 

Antimonium critdum, Arsenicum, Nux vomica and Pulsa- 
tilla are of service in cases arising from gastric irritability. 

In the chronic form Hepar sulph. c. may be looked upon as 
specific. 

YKGETABLE PARASITIC DISEASES; TINEA. 

The term tinea embraces the vegetable parasitic diseases 
of the skin. Those due to the trichophyton fungus are spoken 
of as tinea trichophytina. Tinea trichophytina affects the 
scalp and body. 



412 DISEASES OF CHILDREN. 

TINEA TONSURANS. 

Synonyms. — Trichophytosis tonsurans, ringworm of the 
scalp. 

Definition. — Tinea tonsurans is a highly contagious vege- 
table parasitic disease of the scalp, characterized by the pres- 
ence of one or several bald spots, covered with scales and con- 
taining short, broken-off hairs. 

Symptomatology. — Following a period of incubation, 
variously estimated at from three to five days, erythematous 
areas about the size of a twenty-five-cent-piece appear. They 
are covered with grayish scales, and are accompanied by 
slight itching ; they enlarge peripherally and may coalesce. 
The hairs of these parts become lustreless and break off. In 
some cases the scalp is entirely denuded, making a complete 
bald spot. Occasionally vesicles and pustules form, and a 
certain amount of suppuration results. Resolution may take 
place in one area, while the disease is active in another. The 
general health is rarely affected. 

Etiology. — Tinea tonsurans is due to the presence and 
growth of the trichophyton fungus. It is highly contagious, 
being transmissible to the lower animals, from whom it may 
be contracted. It is often endemic in asylums and hospitals, 
or where a number of children are congregated. 

Pathology. — As a rule, only the superficial parts of the 
epidermis and hair are attacked in children. Microscopically 
mycelia and spores are seen. The hairs become brittle, but, 
as a rule, baldness is not permanent. The hairs usually re- 
turn to their normal state. 

Diagnosis. — Ringworm of the scalp may be mistaken for 
alopecia areata and squamous eczema. 

Alopecia areata. — Baldness in alopecia areata is complete. 
The condition develops quickly. It may be associated with 
ringworm of the scalp. 

Prognosis. — Isolated cases, if seen early and subjected to 
proper treatment, are curable within a few weeks. An epi- 



DISEASES OF THE SKIX. 413 

demic occurring where a number of children dwell together 
is hard to eradicate. In the majority of cases a few months 
will be required to efface the disease, and it must be remem- 
bered that relapses are common. 

Treatment. — The treatment of ringworm of the scalp is 
difficult and tedious. Internal remedies will be required to 
prevent suppuration, in which event Hepar is indicated, or, 
where anaemia or scrofula exists, Arsenicum, Thuja, Mercn- 
rins and Sulphur may be advantageously employed. The 
best results in all cases are obtained from the application of 
parasiticides. It first becomes necessary to place the scalp in 
a condition suitable to receive local treatment. The hair 
about the patch and for some space surrounding it should be 
cut and the scalp closely shaven. The short hairs should be 
removed by means of suitable forceps. Scales and crusts, if 
present, are removed by scrubbing vigorously with a solution 
of green soap. Where the patches are extensive, it is neces- 
sary to shave the entire scalp. Depilation of the diseased 
hairs is tedious and often unsatisfactory. As a rule the hair 
is brittle and breaks oil, not coming out entirely. The pro- 
cess, however, should be practiced daily.' Locally the best 
application is Bichloride of Mercury, one to one thousand ; it 
should be discontinued if it excites active inflammation. Car- 
bolic acid, one drachm to one pint of water, is frequently effi- 
cacious. Among other agents are Sulphur ointment, a five 
per cent, ointment of the Oleate of Mercury, and equal parts 
of the Oil of Cade and Olive oil. After an apparent cure, the 
scalp should be treated every other day, to prevent the possi- 
bility of a relapse. 

TINEA CTRCIXATA ; RINGWORM. 

Tinea circinata is a highly contagious vegetable parasitic 
disease of the skin, caused by the trichophyton fungus. It is 
characterized by the presence of several patches of varying 
size and character, occurring upon any part of the body sur- 
face. 



414 DISEASES OF CHILDREN. 

Symptomatology. — Ringworm of the scalp and ringworm 
of the body are often found co-existing. Minute, irregular- 
shaped spots of a reddish-brown color indicate the commence- 
ment of ringworm of the body. L,ater a distinct circular 
patch is seen, which heals in the centre and spreads peri- 
pherally. Around the margin of each patch small papules 
and papulo- vesicles are seen. Scaling is a distinct feature. 
The typical ringworm is usually about the size of a dime, 
and it stands out prominently from the surrounding skin. In 
some instances the rings join together. Any part of the 
body may become affected, although the face and hands are 
most frequently attacked. Next to these localities, the 
axillary and inguinal folds are involved. 

Etiology. — Tinea circinata is due solely to the presence of 
the trichophyton fungus. The disease is highly contagious. 
Adults are often attacked. It is, however, more common in 
childhood. 

Diagnosis. — Tinea circinata may be mistaken for sebor- 
rhea and eczema squamosum. In seborrhoea the scales are 
greasy and the fungus is absent. Should any doubt exist as 
to the diagnosis, a microscopical examination will usually de- 
tect the fungus. 

Prognosis. — An acute attack is quickly curable, but in the 
anaemic and poorly nourished it may be quite rebellious to 
treatment. 

Treatment. — The fungus can be destroyed by scrubbing 
the lesions every morning and evening with green soap and 
hot water, and afterwards applying a solution of Sodium Hy- 
posulphite (drachm to the ounce) or painting the patch with a 
weak Iodine tincture. In obstinate cases it may be necessary 
to resort to a 25 per cent, aqueous solution of Ichthyol. Care 
must be observed in using Ichthyol, since it is likely to pro- 
voke an acute dermatitis. Internally Hydrastis, Natrum 
muriaticum, Sepia or Graphites may be indicated. 



DISEASES OF THE SKIX. 415 

ANIMAL PARASITIC DISEASES: PEDICULOSIS ; LICE. 

Definition. — Pediculosis is a contagious animal parasitic 
disease, in which the body is infested with lice. These set 
up both primary and secondary lesions. 

Symptomatology. — In infants and children pediculosis is, 
as a rule, confined to the scalp. The uncleanly are mostly 
attacked. These parasites attack the scalp, causing much 
itching and scratching ; escape of serum and purulent fluid 
occurs, forming crusts. The hairs become matted together ; 
scratch-marks, pustules, excoriations and furunculi contribute 
to this unsightly condition. The cervical glands become 
tumid and enlarged. 

Occasionally an eczematous condition of the scalp accom- 
panies pediciriiis capitis. Pediculi are found both upon the 
scalp and the hairs. Their nits are usually upon the hairs. 
The term plica polonica has been applied to an aggravated 
state of lousiness, where living and dead lice and their 
nits have matted the hairs together, a most offensive odor 
arising from the decomposing pus and crusts. Severe in- 
roads are in some instances made upon the general health, 
traceable to the annoyance coincident to incessant itching and 
scratching. 

Diagnosis. — The detection of pediculi and their nits, to- 
gether with their resulting secondary changes, will at once 
establish the diagnosis. 

Treatment. — Naturally local treatment is indicated. Kero- 
sene oil is the best remedy with which to kill the parasites 
and their ova. It should be applied freely, and the scalp sub- 
sequently covered with a muslin or oiled-silk cap. On the 
following day the head should be shampooed with soap and 
water followed by the liberal application of diluted vinegar, 
which dissolves the nits. This procedure may have to be re- 
peated a number of times before a cure is completed. Should 
eczema of the scalp be present it must receive suitable treat- 
ment. Xo internal remedy is indicated, except in debilitated 
subjects. These must be prescribed for symptomatically. 



416 DISEASES OF CHILDREN. 

SCABIES ; ITCH. 

Definition. — Scabies is a contagious animal parasitic dis- 
ease of the skin, which is produced by the acarus scabiei. 

The male itch-mite rarely burrows beneath the epidermis. 
The female, however, penetrates deeply, making minute tun- 
nels, which serve as its habitat. The acarus selects those 
regions where the skin is tender, as the axillary and inter- 
digital spaces, producing papules, vesicles, pustules, bullae, 
wheals, infiltrations, furuncles and crusts. 

Pathology. — Inflammation of the papillary layer of the 
skin results from the presence of the acarus. Itching, which 
is usually intense, is a very distressing symptom. It is par- 
ticularly severe during the sleeping hours, since the female 
acarus is most active when the patient is protected by the 
warmth of the bed-coverings. 

Etiology. — Uncleanliness invites the disease. Personal 
contact covering a prolonged period is also responsible. The 
itch-mite alone is the exciting cause. 

Diagnosis. — The diagnosis of scabies is not attended with 
any difficulty. The presence of characteristic lesions, situ- 
ated in the interdigital and other favorite regions, associated 
with marked and distressing itching, should lead one to a 
positive opinion. Scabies may, however, be mistaken for 
eczema and pediculosis. 

Eczema. — This disease presents many, but by no means all, 
of the multiform lesions which accompany scabies. Itching 
is confined to the diseased parts. Pediculosis causes itching 
only of the parts attacked. Itching as a symptom of scabies 
is frequently referred to parts unattacked. Some confusion 
may exist where eczema or impetigo occurs in a subject al- 
ready affected with scabies. 

Prognosis. — A rapid recovery may be expected where anti- 
parasitic treatment is instituted early; otherwise, scabies may 
assume a somewhat intractable feature. 
) ne of the best and least irritating remedies to destroy the 



DISEASES OF THE SKIN. 417 

itch-mite is Balsam of Peru. This may either be used alone — 
rubbed well into the infected site after thorough scrubbing 
with green soap and hot water — or combined with sublimated 
sulphur, one drachm of each to the ounce of vaseline. The 
treatment should be carried out night and morning for three 
days, after which a complete change of clothing and bed- 
clothes is to be made and the child given a hot bath. The 
clothes should be baked before putting them into the wash. 

Dermatitis, if excited, may be controlled by discontinuing 
the use of the ointment and instituting appropriate treatment. 
Occasionally the health becomes undermined by reason of the 
incessant itching and scratching. In such instances internal 
remedies are indispensable. 

Sulphur is an ideal remedy. It is particularly indicated in 
scrofulous and uncleanly children and is helpful in the cure 
of the associated lesions. 

Arsenicum may be administered where anaemia, prostration 
and marasmus complicate the disease. 

Hepar sulphur, calc. possesses decided virtues in scabies, as 
well as in many other skin diseases presenting lesions of a 
vesico-pustular character. 



CHAPTER XV. 

DISEASES OF THE BLOOD. 

The total amount of blood in the body of a child is some- 
what less in proportion to the body weight than in the body 
of an adult. Likewise the specific gravity is lower, the aver- 
age being 1052 as compared to 1055 in adults. It bears a 
close relationship to the amount of haemoglobin, which is also 
proportionately low during infancy and early childhood. In 
the new-born, however, the haemoglobin percentage is high, 
but thereafter it rapidly falls, ranging between 55 and 85 per 
cent. Under ordinary circumstances 60 per cent, may be ac- 
cepted as the limit of blood poverty compatible with health. 

The red corpuscles, or erythrocytes, are most numerous at 
birth. Even during the period of infancy they remain rela- 
tively more numerous than in childhood and in adult life. They 
gradually decrease from six to six and a half million per cubic 
millimeter at birth to four and a half to five and a half million 
in early childhood, and the normal standard of four and a half 
to five million is attained later in childhood. Fluctuations in 
the number of erythrocytes is, however, more common than 
in adults; even daily variations can be observed. 

The form of the red corpuscle is variable in the new-born, 
and nucleated corpuscles (normoblasts) may be seen. The cor- 
puscles also readily lose their haemoglobin, forming the so- 
called shadows of Silbermann. Variations in form, and the 
occurrence of nucleated red corpuscles later in childhood, are, 
however, always pathological (GeisslER and Japha). 

The leucocytes are relatively more numerous than in adults. 
In the new-born an actual leucocytosis exists. According 
to Hayem there may be as many as 18,000 leucocytes to the 
cubic millimeter, but they fluctuate widely under slight in- 
fluences, such as diet. The ratio of leucocytes to erythrocytes 



DISEASES OF THE BLOOD. 4-19 

in sucklings is, according to Gundobin, 1-395; ^ n older chil- 
dren, 1-400 to 590. Rieder found a moderately high propor- 
tion of leucocytes at birth, with a decrease on the second to 
fouith day, after which the number of white cells again rose. 

The various forms of leucocytes are: (a ) Lymphocytes, or 
small mononuclear cells, which are believed to originate from 
the lymphoid tissue. They are about the size of a red blood 
corpuscle and contain a single large nucleus which almost 
completely fills the cell. A narrow rim of strongly basophile, 
homogeneous or coarsely reticular cytoplasm surrounds the 
nucleus. Normally (in adults) they constitute about 25 per 
cent, of the total, but in infants there may be 50 to 70 per 
cent. (Gundobin). The lymphocytes are most markedly in- 
creased in lymphatic leukaemia. An actual increase is also 
noted in manv cases of rickets, and a physiological increase 
occurs after feeding. Passive hyperleucocytosis — due to the 
mechanical washing out of certain lymphatic districts into the 
blood current — is observed in gastro-intestinal disturbances 
and in whooping-cough. A relative lymphocytosis occurs 
during the second and third week in typhoid fever. 

(b) Lai r ge mononuclear cells, derived from the bone marrow 
and spleen. They are much larger than the preceding form 
and are not so numerous, constituting about 6 per cent, of the 
different forms. In infancy the percentage is higher, while 
in the foetus they are the most numerous. The nucleus is 
vesicular, does not stain as deeply as that of the small leuco- 
cyte, and at times has an indented, horse-shoe appearance, 
believed to be a stage of transition to the poly nuclear form. 
The protoplasm is faintly basophile and may show a fine 
reticulum. On account of their light staining they are often 
spoken of as "hyaline cells." These cells are increased, as a 
rule, in conjunction with the lymphocytes, but they are es- 
pecially increased in the so-called anaemia infantum pseudo- 
leukaemia, and in malarial fever. In malarial infection there 
is not only an absolute increase in the large mononuclear 
cells, but also a relative increase over the small lymphocytes. 



420 DISEASES OF CHILDREN. 

They are also increased in measles, and in syphilis, tubercu- 
losis and in typhoid fever, when these diseases become well 
established. A differential count of these cells, therefore, 
plays an important role in the diagnosis of obscure febrile af- 
fections. In cases of malarial infection without much fever 
and without quinine history the polynuclears are diminished 
and the large lymphocytes much increased (Krauss, Jour. 
Amer. Med. Ass., Oct. 22, 1904). This also holds good in 
recent cases. As some difficulty may arise in distinguishing 
between a large and a small lymphocyte, Krauss gives the 
following rule: "Class all cells the size of a poly nuclear cell 
as small unless the protoplasmic margin is relatively large, 
and contains scattered neutrophile granulations, which stamps 
the cell as a large one." 

(c) Polynnclear leucocytes, or neutrophiles. They are large 
leucocytes with several nuclei connected by threads, therefore 
they are also called "polymorphonuclear." The nucleus takes 
the basophile stain while the protoplasm is neutrophile and 
contains distinct granulations. They are the most numerous 
of all leucocytes, excepting in infancy, constituting from 65 
per cent, to 70 per cent, under normal conditions. In the 
new-born the polynnclear leucocytes represent about 63 per 
cent, of the white corpuscles and they rise to 70 per cent, in 
the first forty-eight hours. After that a rapid destruction of 
these corpuscles takes place and they fall to about 35 per 
cent. They are rapidly increased in infectious diseases, act- 
ing as phagocytes. These cells form the pus cells in all active 
suppurative processes. In infancy the percentage of polynn- 
clear leucocytes is much lower than in mature children, 
ranging between 28 and 40 per cent. (Gundobin, Rieder). 

{d) Eosinophile leucocytes are large, round, polynnclear cells 
containing coarse, granular bodies which stain deeply with 
eosin. Their affinity for this stain gives them their name. 
Normally but 2 to 4 per cent, are encountered, but in leukae- 
mia there is both a relative and an absolute increase. 

(e) Myelocytes, or Markzellen, being so named from their 



DISEASES OF THE BLOOD. 421 

origin in the medullary cavity of long bones. They are never 
found in the blood under normal conditions. They are sev- 
eral times larger than a red blood corpuscle, and have a single 
nucleus that stains but faintly. The protoplasm contains 
neutrophile granulations. They are found in spleno-medul- 
lary leukaemia in conjunction with an increase of the eosino- 
philes, and in severe secondary anaemias. 

(/') Mast-cells are variously sized leucocytes, either mono- 
or polynuclear, their protoplasm containing strongly basophile 
granules. They are found in a small proportion in normal 
blood, but in leukaemia, and especially in the secondary anae- 
mias of childhood, they are considerably increased. 

The necessary data for a correct diagnosis of a pathological 
blood condition can only be obtained by a direct examination 
of the blood. This resolves itself into the following steps : 

i. The determination of the percentage of hemoglobin. To 
ascertain this, the Haemometer of v. Fleischl is the instrument 
usually employed. A capillaiy tube holding a definite quan- 
tity of blood is filled by holding its free end over a drop of 
blood which is allowed to ooze from a puncture of the ear 
lobe. The blood is diluted with water in a chamber divided 
into equal halves, and by artificial light transmitted from be- 
low, the colored water is compared with the gradually increas- 
ing shade in the color of a wedge of properly colored glass 
that is passed under the other half of the chamber, in which 
distilled water has been placed. As soon as the two halves 
are identical in shade, the scale is consulted and the percent- 
age read off. 

2. The determination of the number of red corpuscles. For 
the purpose of counting the red corpuscles the Haemocyto- 
meter of Thoma-Ziess is used. This instrument is supplied 
with a pipette graduated to hold one millimeter of blood 
and one hundred millimeters of diluting fluid. The blood is 
thoroughly diluted with a solution corresponding to the blood 
serum in density (Gower's solution) and a drop is then placed 
upon a counting chamber ruled off into squares so that the 



422 DISEASES OF CHILDREN. 

number of corpuscles in a cubic millimeter can be accurately 
estimated by counting off a large number of these squares. 

3. The determination of the white corpuscles is carried out 
on the same principle, but, as they are less numerous, a larger 
pipette, giving a dilution of one to ten, is employed. A 3 per 
cent, solution of Acetic acid is used as a diluting fluid. This 
destroys the erythrocytes and renders the leucocytes more 
conspicuous. 

4. The differential count of the leucocytes is conducted by 
making a film of blood on a microscopical slide, drying it and 
staining with eosinate of methelyene blue (Jenner's stain). 
Several hundreds are then counted and classified, when the 
percentage of each variety of leucocytes is easily computed. 

5. The microscopical appearance of a fresh drop of blood is 
of great importance for diagnostic purposes. The shape and 
size of the red corpuscle, the absence of rouleaux formation, 
the presence of nucleated red corpuscles, the presence of para- 
sites (plasmodium of malaria), must all be taken into consid- 
eration. 

6. The specific gravity is obtained by floating a drop of 
blood in a mixture of Chloroform and Benzol of 1050 to 1060 
specific gravity. A drop of blood is allowed to fall into a test 
tube containing ten cubic centimeters of the fluid, and, ac- 
cording as it drops to the bottom or floats on the surface, 
Chloroform or Benzol is added. When it remains suspended 
in the fluid the specific gravity of the latter is taken, it corre- 
sponding to the specific gravity of the blood drop. For a full 
description of the instruments, technique and methods of 
blood study the various works on hematology must be con- 
sulted. 

ANAEMIA. 

The various forms of anaemia occurring during infancy and 
childhood are not well understood. The majority of cases 
are purely secondary to some constitutional disturbance or de- 
pendent upon indigestion or malassimilation. The marked 



DISEASES OF THE BLOOD. 423 

difference between the blood of the infant and that of the 
adult, especially in the wide range of fluctuations to which it 
is subject both in its chemical and morphological elements 
and the strong tendency to reversion to the embryonic type 
makes it difficult to determine just where one form of anaemia 
begins and another ends, or even to determine definitely the 
actual presence of a pathological blood-state. It is becoming 
more and more the conviction of hsem otologists to question 
whether a primary form of ansemia is ever encountered in 
children; and whether there be such a clinical entity as 
pseudo-leukczmia infantum of v. Jaksch — a disease in which 
the blood shows changes similar to those observed in leukae- 
mia, but in which recovery may take place. 

Again, the mere presence of leucocytosis is not a sufficient 
datum for classifying an ansemia, it being necessary to deter- 
mine the proportion of the various forms of leucocytes. 
Neither can splenic tumor be employed as a means of differ- 
ential diagnosis in anaemias, as this may be present even when 
there is no ansemia (GEISSLER and Japha). In the ansemia 
associated with rickets, a condition of the blood showing all 
of the stages of ansemia may occur, from a slight diminution 
of the haemoglobin and of the red corpuscles to the occurrence 
of magaloblasts. There also may be splenic tumor. While 
such a condition is sometimes described as ancemia splenica, 
still there are no grounds for looking upon it as a primary, 
independent disease. If we simply remember that the child's 
blood is particularly susceptible to deterioration, and that a 
strong tendency exists for the blood to revert to a less mature 
histological type, we will not misinterpret the various blood 
changes encountered at this time of life. 

Ischcrmia, or local ansemia, a condition resulting from an 
interference with the circulation in a localized portion of the 
body is a purely mechanical condition and not to be consid- 
ered here. 

Secondary, Sin/pie, or Symptomatic Ancemia comprises the 
class of cases resulting from haemorrhage, inanition, intestinal 



424 DISEASES OF CHILDREN. 

parasites, errors of feeding, unhygienic surroundings, rickets, 
nephritis, long continued suppurative processes, syphilis, tu- 
berculosis, malaria and other forms of infections and from cer- 
tain poisons such as Lead, Mercury and Arsenic. Secondary 
anaemia may be divided into several types, the following class- 
ification being after Morse {Archives of Pediatrics, 1898). 

Mild ancemia, characterized by trifling reduction in the 
haemoglobin percentage and number of erythrocytes and ab- 
sence of abnormal changes in the blood elements. 

Severe ancemia with pronounced diminution of haemoglobin 
and erythrocytes, together with changes in the size and shape 
of the corpuscles and the presence of normoblasts, or nucleated 
red blood corpuscles. 

An<ztnias with leucocytosis are usually associated with more 
pronounced reduction in haemoglobin and red corpuscles than 
anaemias without leucocytosis (Da Costa). Normoblasts and 
deformities in size and shape of the erythrocytes are encount- 
ered in these cases. 

CHLOROSIS. 

Chlorosis is a form of primary anaemia which is seen most 
frequently in girls at the time of puberty, but it is not neces- 
sarily confined to this period of life nor to the female sex. 
Of the etiology nothing positive is known excepting that un- 
hygienic surroundings, improper or insufficient food, lack of 
fresh air and sunshine, emotional disturbances and obstinate 
constipation are frequently intimately associated with the 
development of chlorosis. The heait and larger blood-vessels 
have been demonstrated by Virchow as under-developed in 
many instances. 

The symptoms of chlorosis may make their appearance 
rapidly, or the disease may not be suspected for a long time 
until pallor and the characteristic greenish tint of the skin, 
on account of which it is popularly known as "green sick- 
ness," give a clue to the existing ill-health. The child com- 
plains of headache, and displays an aversion to mental or 



DISEASES OF THE BLOOD. 4-25 

physical exertion of any kind. The latter results in dyspnoea 
and palpitation, while the headache and languor induce in- 
difference both to work and to play. 

The appetite is poor, and in many instances becomes per- 
verted, so that the patient craves chalk, slate-pencils, coffee- 
beans, etc., which are apparently enjoyed. Indigestion and 
constipation are troublesome symptoms, and their correction 
materially hastens the cure. 

In young girls, menstrual derangements are inseparably as- 
sociated with chlorosis. Thus, scanty menstruation or amen- 
orrhcea are almost invariably encountered in these cases; like- 
wise, dysmenorrhcea and leucorrhcea are common. Improve- 
ment in the chlorotic condition results in prompt improve- 
ment here. 

The red coipuscles are but slightly decreased in number, 
but there is a pronounced deficiency of haemoglobin, giving 
the individual corpuscles a noticeably pallid appearance. 

CEdema tends to develop about the ankle-joints, and many 
patients present a puffy, fat appearance, indicating a hydraemic 
state, with sluggish return circulation. The degree of anaemia 
can be roughly estimated by the appearance of the palpebral 
conjunctiva, the lips and the matrix of the nails, but in order 
to follow the progress of the case accurately we should make 
weekly haemoglobin estimations with the haemometer of v. 
Fleisch, or with Dare's haemoglobinometer. A less accurate, 
but very simple procedure, yet at the same time a far better 
method than the pure guesswork of merely inspecting the 
mucous membranes, is afforded us in the Tallquist scale. 
Here it is only necessary to place a drop of blood upon a 
piece of absorbent paper and compare it with the scale at- 
tached to the book. 

The prognosis of chlorosis is favorable, and it usually re- 
sponds promptly to treatment, although there is liability to 
relapses. As it creates a tendency to tuberculosis it becomes 
dangerous when occurring in individuals with tuberculous 
antecedents. 
28 



426 DISEASES OF CHILDREN. 

PROGRESSIVE PERNICIOUS ANAEMIA. 

This form of primary anaemia is a rare disease, and is more 
seldom seen in children than in adults. Quite a sufficient 
number of cases, however, are on record to assign it at least a 
brief mention in a work upon the diseases of children. The 
etiology is obscure. Birch-Hirschfeld advances the infectious 
theory, owing to the presence of tissue destruction and retard- 
ation of blood-coagulation ; others hold to the theory of in- 
creased haemolysis, and again others to decreased haemogen- 
esis. Stengel {Medical News, Oct. 20, 1900) expresses the 
view that pernicious anaemia is undoubtedly a disease result- 
ing from the rapid destruction of red blood corpuscles, for 
the compensation of which the blood-making functions prove 
inadequate; and, further, that the source of the haemolytic 
agents is the gastro-intestinal tract. 

The anaemia resulting from intestinal parasites is very dif- 
ficult to distinguish from pernicious anaemia, showing the 
great liability for error and the difficulty with which a study 
of the disease is beset, as so many agencies are capable of 
inducing pronounced anaemia. In eighteen cases seen by 
Osier (Amer. Text-Book of Practice) there was absolutely no 
appreciable cause for the disease. Henoch (Vorlesungen it. 
Kinderkrankh.) saw two children in the same family die of 
this disease, no cause being ascertainable. Ewing thinks 
that any case of pronounced, progressively-increasing anaemia 
in which the blood contains megaloblasts and a considerable 
proportion of megalocytes. with increased haemoglobin, while 
the lymphoid marrow shows marked hyperplasia of peculiar 
type, should be considered one of pernicious anaemia, regard- 
less of the immediate exciting cause. Even in the gravest 
secondary anaemias these changes are rare, but in early life 
the changes in the blood are so uncertain that their signifi- 
cance is difficult to determine. The frequency of pernicious 
anaemia in childhood, therefore, is still a question. 

The symptoms are those of a gradually increasing anaemia. 



DISEASES OF THE BLOOD. 427 

Loss of flesh may be absent. CEdema and haemorrhage may 
supervene. The skin assumes a characteristic lemon-yellow 
tint. Anorexia, vomiting and other digestive disorders ac- 
company the condition. The patient eventually dies from 
exhaustion. As the name implies, the entire course is a pro- 
gressive and pernicious one. The blood changes are the 
same as found in the adult as far as pronounced oligocythae- 
mia and nucleation and deformities of the erythrocytes are 
concerned, but the blood often fails to show the high color 
index and the prevalence of megaloblasts and of megalocytes 
that are accepted as diagnostic of the disease in adults (Da 
Costa). 

Treatment. — The hygienic management of cases of anaemia 
is important, and the physician must study his patient care- 
fully, before determining upon the question of diet, exercise 
and rest. In chlorosis it is especially important to improve 
the condition of the bowels, and the selection of a diet to 
overcome constipation is a great advantage to the patient. 
Fruits and fresh vegetables, many of which are rich in iron 
(notably spinach), are very beneficial. For anaemia in general 
it may be said that the most nutritious and most digestible 
form of food is to be selected. The impoverished and watery 
condition of the blood diminishes the organic elements of the 
digestive secretions, for which reason it is often desirable to 
aid the digestion by the employment of digestive ferments, 
such as pepsin cr papain, or, as Thompson {Practical Dietetics) 
recommends, to employ predigested foods, making use of pan- 
creatin in the preparation of animal food and diastase or malt 
extracts for the predigestion of amylaceous food. 

Milk is an ideal food in all forms of anaemia, and chlorotic 
subjects may drink of it freely, even between meals. Eggs 
are also very beneficial, being easily digested, and their yolk 
contains a large proportion of iron. There is some risk in 
using raw beef, but meat is usually not well digested by these 
patients unless given practically raw. A good red wine often 
proves most beneficial. 



428 DISEASES OF CHILDREN. 

Where exhaustion is a prominent symptom, rest rather than 
exercise should be prescribed. Absolute rest in bed, with 
massage and liberal feeding, will accomplish more in such 
cases than exercise, which only adds to the exhaustion and 
tissue breakdown. 

The following remedies are the ones most useful in the 
various forms of anaemia : 

Belladonna. — In chlorosis, when there is violent palpita- 
tion, throbbing headache, great weariness and desire to sleep 
in the afternoon, debility. The symptoms of Belladonna are 
very similar to those of Ferrum, especially the palpitation, 
dyspnoea and rush of blood to the face, alternating with pale- 
ness ; but there is not that intense anaemia and persistent de- 
bility, gastralgia, vomiting, amenorrhcea and anasarca indi- 
cating the latter remedy. 

Ferrum is seldom of use elsewhere than in chlorosis, to 
which it is strictly homoeopathic, as indicated by its symp- 
tomatology. Here it has gained universal reputation, and 
even as prescribed empirically by the old school in large doses 
it is frequently of great benefit, owing to its favorable action 
upon the intestinal tract, by uniting with the hydrogen sul- 
phide gas in the intestines. In this way the assimilation of 
the organic iron compounds present in the food is permitted, 
an impossibility in the presence of free hydrogen sulphide 
gas. No doubt such remedies as Pulsatilla, Nux vom. and 
Spigelia owe their prominent usefulness in chlorosis to their 
influence upon the alimentary tract, and when they are indi- 
cated the use of Iron is not always necessary for the cure, as 
sufficient iron should be absorbed from the food to supply the 
blood with all it requires. Iron is no doubt a specific food in 
chlorosis, for in this form of anaemia the erythrocytes are not 
diminished in great number, the chief disturbance being the 
reduction in haemoglobin and the consequent low color index. 
Iron supplies the necessary element, and thus the haemoglobin 
is restored. It is different with other forms of anaemia, in 
which the blood elements themselves are deficient. As iron 



DISEASES OF THE BLOOD. 429 

dees not act upon the haematopoietic organs it cannot be ex- 
pected to benefit such cases, and here we must look to rem- 
edies like Arsenic and Mercury for results. Many prepara- 
tions of iron are in vogue, each form having its ardent advo- 
cates. Ferrum redactum in the first decimal trituration is 
one of the most reliable preparations ; the Oxalate of Iron 
finds great favor with many of the British homceopathists in 
chlorosis. The Citrate of Iron and Strychnia, second decimal 
and third decimal trituration, is a preparation which stands 
highly recommended for cases in which debility is a promi- 
nent symptom. 

Graphites. — Chlorosis, tendency to obesity, sluggish circu- 
lation and anaemia, with general coldness ; delayed or scanty 
menses, obstinate constipation; sad, tearful disposition. 

Nat rum mur. — Chlorosis, obstinate cases, fluttering of the 
heart, craving for salt. 

Nux vom. — Chlorosis, gastric derangements, constipation, 
irritability, prostration; languid, especially morning on rising 
from bed; perverted appetite. 

Pulsatilla. — Chlorosis; great weakness and sluggishness of 
the circulation, manifesting itself as chilliness ; coldness and 
paleness of face, relief in open air. Anorexia, nausea, palpi- 
tation of heart and dyspnoea, sharp pains about heart (com- 
pare also Spigelia and Cactus, both of which are indicated by 
their cardiac symptoms), amenorrhcea, leucorrhcea; sad, tear- 
ful disposition. Cyclamen is similar to Pulsatilla, but this 
remedy has aggravation of symptoms in the fresh air, due to 
great sensitiveness to cold. 

Other important remedies in chlorosis are Calc. c, Helonias, 
Sepia and Sulphur 

Symptomatic anaemia finds in China a most valuable drug. 
China is indicated after haemorrhages, chronic diarrhoea, long- 
continued suppuration, and in all mild forms of idiopathic 
anaemia as a " tonic," given in doses of two to three drops of 
the tincture, three to four times daily. 

Arsenicum corresponds more closely to the pernicious forms 



430 DISEASES OF CHILDREN. 

of anaemia than any other remedy, and is also indicated in 
the anaemia of malaria and of Bright's disease. Its indica- 
tions are excessive debility, oedema of the ankles and eyelids, 
cardiac weakness and dyspnoea, gastric irritability. It may 
also be required in severe cases of chlorosis. 

Phosphoric acid and Silicea are useful in the anaemia of de- 
bilitating diseases, such as typhoid fever, following well after 
China. 

Mercurius is specific in the anaemia of syphilis. 

Kali carb. corresponds to a vitiated state of the blood 
plasma. Farrington refers to its ability to produce anaemia, 
and recommends it for the blood poverty after severe or pro- 
tracted diseases. The following symptoms are recorded in Her- 
ing's Condensed Materia Medica : u Vertigo, congestion to head 
with throbbing and humming. Swelling like a bag between 
upper eyelids and eyebrows. Palpitation in spells, taking his 
breath ; stitches about heart ; weak, irregular pulse. Arms 
go to sleep. Swelling of feet to ankles. Anaemia, with great 
debility ; skin milk-white ; muscles weakened, especially the 
heart." Our claims for the value of this remedy .in anaemia 
have been substantiated lately by old school therapeutics- 
Denstedt and Rumpf {Therapeutische Monatshefte, March, 
1901) demonstrated that in pernicious anaemia the blood gave 
a high percentage of water and sodium chlorid and a great 
reduction in the percentage of iron and potash. Accordingly, 
Potash salts were administered in several such cases, both by 
mouth and infusion, with marked improvement. It seems 
that the death of the corpuscles depends upon the abstraction 
of its potash, and Potash, therefore, has the same specific re- 
lationship to degenerative changes in the corpuscles that Iron 
has to haemoglobin poverty in the corpuscles (chlorosis) and 
Arsenic to the making of new blood elements, haematosis. 



DISEASES OF THE BLOOD. 431 

LEUKAEMIA; PSEUDO-LEUKEMIA; SPLENIC ANEMIA; 
. HODGKIN'S DISEASE. 

The varieties of anaemia described under the above titles 
present as their most characteristic features permanent leuco- 
cytosis and splenic enlargement. 

Their differentiation presents many points of difficulty, 
which can only be definitely settled by careful haematological 
examinations. Aside from the pseudo-leukaemic anaemia of 
infants, they are seldom encountered during childhood. They 
all present an unfavorable prognosis. 

Leukaemia may affect persons of all ages, but is rare dur- 
ing childhood. Mossa has collected a series of twenty-seven 
cases in children, but he admits that a large number of these 
were undoubtedly not cases of true leukaemia. Da Costa col- 
lected ten cases, in all of which a differential leucocyte count 
is recorded, confirming the diagnosis. 

The symptoms are anaemia, pronounced pallor, distended ab- 
domen, with enlargement of the spleen, and tenderness. The 
lymphatic glands may be principally involved, as in the lym- 
phatic variety, or the spleen and marrow, in the spleno-medul- 
lary variety. In the lymphatic variety the lymphocytes are 
markedly increased, sometimes the large, at other times the 
small mononuclear cells predominating. The polynuclear 
cells are relatively decreased. In a case coming under my 
notice the polynuclear cells had almost entirely disappeared 
from the blood, the blood-count giving five thousand leuco- 
cytes, mostly lymphocytes. The erythrocytes are diminished 
and a few normoblasts may be present. In the spleno-medul- 
lary variety there is a relatively small increase in the lympho- 
cytes, but myelocytes are found in abundance in conjunction 
with an increase in the eosinophile cells. 

The disease assumes a progressively downward course, usu- 
ally terminating in general oedema, haemorrhages and ex- 
haustion. At times it is febrile, simulating an infectious dis- 
ease, and runs an acute course. 



432 DISEASES OF CHILDREN. 

Hodgkin's disease presents enlargement of various groups 
of the lymphatics ; enlargement of the spleen and liver ; 
fever of an intermittent type, and progressive anaemia and 
leucocytosis ; but the latter never attains to the degiee found 
in leukaemia. The cervical and axillary glands, or those situ- 
ated near by, are usually the ones first affected, other groups 
eventually becoming implicated. They do not, however, tend 
to break down, this being a strong point of differentiation be- 
tween Hodgkin's disease and tuberculous adenitis. The 
course is chronic, and although the child may live for a long 
time, still it ultimately succumbs. 

Pseudo-leukaemia, or Aiicemia Infantum Pseudoleukcemica 
(v. Jaksch), is a disease of childhood, usually seen before the 
second year. The etiology is obscure. It was first described 
by v. Jaksch, its characteristics being : Occurrence in infancy ; 
oligocythemia and oligochromaemia ; permanent leucocytosis ; 
marked splenic enlargement, and at times lymphatic enlarge- 
ment. The liver is but slightly enlarged, a clinical distinc- 
tion between this disease and leukaemia. The prognosis is 
more favorable than in the latter disease, but many cases 
prove fatal nevertheless. The term splenic anaemia has been 
applied to a class of cases similar in all respects with the 
above, excepting in that leucocytosis is absent. 

The development of pseudo-leukaemia is one of progressive 
pallor, failure in general health, digestive disturbances, and 
at times slight pyrexia. The anaemia is. very noticeable, and 
palpation reveals an enlarged spleen. No doubt many cases 
described as pseudo-leukaemia are in their true nature really 
nothing more than aggravated types of rickets, for anaemia, 
digestive derangements and enlarged spleen are all found in 
well-developed rickets. As has been observed above, the 
present tendency is to doubt the actual existence of this form 
of anaemia as a separate disease. The possibility of a malarial 
and syphilitic influence must also be excluded. The course 
is the same as in the other leucocytoses, the characteristics 
being chronicity and lethal termination, although the chances 



DISEASES OF THE BLOOD. 4-33 

for recovery are greater in pseudo-leukaemia than in Hodg- 
kin's disease or in true leukaemia. 

Treatment. — Homoeopathic literature on these affections is 
meagre. Of our writers, Gilchrist enters most extensively into 
the subject in an article upon " Leucocythsemia " {Arndfs 
System of Medicine) [leukaemia], in which he also reports a 
case of Dr. Gay lord's represented as leukaemia, which, how- 
ever, should be classed as a case of anaemia infantum pseudo- 
leukaemica. The patient was an infant of six months, anaemic 
from birth, living in a malarial district. There was leuco- 
cytosis and splenic enlargement. China 2x and an occasional 
dose of Ferrum resulted in a cure. Dr. Broadbent (PTom. 
Review, vol. xxi) recommends Phosphorus as the most ap- 
propriate remedy in leukaemia, and v. Grauvogl (Lehrbuch 
der Homceopathie) considered Nat7 r um sulph. and Thuja as 
most prominently indicated, for he considered these disturb- 
ances as a form of "sycosis." Gilchrist believes China and 
Phosphorus to be the most closely related remedies to the dis- 
ease. The old school ties to Arsenic in conjunction with 
Iron and Codliver Oil in leukaemia, pseudo-leukaemia and 
Hodgkin's disease, although they claim no positive results 
from this form of treatment. Koplik has used Ichthyol with 
some success in leukaemia. Owing to its strong homoeo- 
pathic relationship to rickets I should look upon Phosphorus as 
the most appropriate remedy in the so-called " splenic " and 
" pseudo-leukaemic anaemias." Picric acid is also recom- 
mended on account of its supposed homceopathicity to leuco- 
cytosis. 

HEMOPHILIA. 

The subjects of haemophilia are commonly known as 
" bleeders," from the tendency to profuse and often uncon- 
trollable haemorrhages which this form of constitution pre- 
sents. The disease is hereditary, and the mode of trans- 
mission is a clear demonstration of atavism through the 



434 DISEASES OF CHILDREN. 

female, as haemophilia rarely occurs in females, being trans- 
mitted by the daughters of bleeders to their male offspring. 

The pathology of haemophilia is not understood. In some 
instances it would seem to depend upon an abnormality in 
the walls of the small blood-vessels, and in others upon a de- 
layed coagulation of the blood. The peculiarity which some 
cases present of only bleeding excessively in certain localities 
would favor the first-mentioned explanation. 

The diathesis usually develops early in childhood, by the 
end of the first dentition period, when an accidental cut or 
injury first attracts attention to this tendency. Beside the 
danger of haemorrhage from a traumatism or an operation, 
there is even as great a one from spontaneous haemorrhage, 
such as epistaxis, haematemesis, haemoptysis, haemorrhage 
from the mouth, intestines, urethra, etc. Injuries without 
destruction of continuity of the skin are followed by profuse 
bloody effusions into the subcutaneous structures. 

The haemorrhagic diathesis cannot be recognized until a 
haemorrhage has taken place, and the subjects are usually 
healthy-looking, apparently robust individuals, character- 
istically supposed to have blonde or reddish hair, blue eyes, 
and a fair, transparent skin. There is a strong tendency to 
joint-affections of a painful type, which may resemble rheu- 
matism of the larger joints closely. When a single large joint 
is involved in a child it is frequently mistaken for a tubercu- 
lous lesion. A haemorrhage may be preceded by an attack of 
arthritis or circulatory disturbances, such as oppression, palpi- 
tation, and rush of blood to the head. 

The prognosis is always grave, one-half of the cases dying 
before the seventh year. As there is a tendency to outgrow 
the condition, the prognosis becomes more favorable with ad- 
vancing years. There seems to be no untoward effect upon 
the functions of menstruation and parturition in female 
bleeders ; another argument in favor of the origin of the dis- 
ease is the vascular system, probably an inherited inefficiency 
in the endothelium of the capillaries distributed over certain 
areas. 



DISEASES OF THE BLOOD. 435 

Treatment. — Fowers {Surgical Diseases of Children ) advises 
against the use of styptics in haemophilia, as they are always 
useless. A case has come under my notice in which the 
thermo-cautery had to be resorted to after the extraction of a 
tooth. The application of fresh blood to the wound has acted 
successfully (Bieudwald). The inhalation cf carbonic acid 
gas (Wright, British Med. Jour., 1894) has a decided in- 
fluence over the epistaxis, which may also require plugging 
of the nares. Supra-renal extract is a most powerful styptic 
and less objectionable than tannin or perchloride of iron. 
Gelatin is highly recommended by some surgeons. 

As a constitutional remedy Phosphorus corresponds most 
closely to the condition. The remedies which have won favor 
in the control of haemorrhages of various types, such as 
Erigeron, Crocus, Hamamelis, Secale, Car bo veg,, China and 
Bell., may prove of use in special cases. 

PURPURA. 

Purpura, or morbus maculosus, includes a variety of affec- 
tions characterized by the development of reddish macules 
of varying size, indicating extravasation of blood into the 
skin. 

It occurs symptomatic ally after the administration of cer- 
tain medicinal substances {Iodide of Potash, Quinine, Bella- 
donna) ; in the course of certain of the infectious fevers, 
notably in septicaemia, cerebro-spinal meningitis, small-pox 
and sometimes in measles; and from cachetic, mechanical 
and neurotic influences. Primarily it is observed in the fol- 
lowing clinical forms: Purpura simplex, purpura rheumatica, 
Henoch's purpura, and purpura hemorrhagica. 

Purpura simplex is characterized by the appearance of 
crops of purpuric spots, mainly upon the legs, which may be 
accompanied by slight fever, articular pains and diarrhoea. 
The spots are bright red in color, do not disappear upon 
pressure, and gradually fade to a purplish and later to a green- 
ish or dirty-yellow shade, as is the course pursued by all pur- 



436 DISEASES OF CHILDREN. 

puric spots. The duration is short, seldom exceeding ten 
days. A rheumatic history is often present. 

Purpura rheumatica, or peliosis rheumatica (Schonlein), 
as the name implies, bears a strong relationship to rheuma- 
tism. The purpuric rash develops in conjunction with mul- 
tiple arthritis. The onset is usually that of an atypical rheu- 
matic fever: lassitude, fever, sore throat, articular pains, and 
in the course of a few days the rash appears, which may be 
associated with urticaria. It is more common in adults than 
in children. 

Henoch's purpura is, according to his own description, a 
complicated clinical picture, in which vomiting, intestinal 
haemorrhage and colic are associated with the purpura and 
articular swellings found in the above-described variety. 
(Vorlesungen u. Kinder kr an kh.). The prognosis of this variety 
is usually favorable, Henoch reporting six cases, with recov- 
ery in all, and Osier eleven cases, with three deaths (Amer- 
Jour, of Med. Sciences, Dec, 1895). The diagnosis is often 
beset with difficulty, especially when there are no external 
signs of purpura. The symptoms may be entirely abdominal 
and I saw a boy operated upon for appendicitis in whom the 
appendix was found to be normal, but the mesentery bled 
freely from the slightest touch. A few days later he developed 
a purpuric rash. Two other cases that came under my notice 
had been treated for gall-stone colic for a long time before the 
true nature of the condition was suspected. 

Purpura haemorrhagica (morbus maculosus JVerlhofii) differs 
from the above forms of purpura in the absence of distinct 
rheumatic manifestations, and in the predominance of the 
haemorrhagic disposition. It most frequently develops in 
young, delicate girls, the onset of haemorrhages being pre- 
ceded by several days of languor, headache, loss of appetite, 
and even moderate fever. The cases that I have seen in in- 
fants proved fatal. The worst case I ever saw. a boy three 
years old, was presented by Prof. Bigler at one of his clinics. 
One of the ears was destroyed and a leg had to be amputated. 
The child eventually recovered. 



DISEASES OF THE BLOOD. 437 

The spots may extend over the entire body, their size vary- 
ing from that of a pin-head to fairly large blotches. The 
macules are often interspersed with vesicles, produced by 
circumscribed haemorrhages into the rete Malpighii. The 
cutaneous haemorrhages are followed by bleeding from the 
mucous membranes and internal organs, particularly from 
the kidneys. The duration is from ten days to two weeks in 
favorable cases. Death may result from gradual exhaustion, 
or from a sudden extensive haemorrhage or a cerebral haemor- 
rhage. 

Purpura fulminans is a variety of purpura haemorrhagica 
occasionally seen in children. It is characterized by its rap- 
idly-developing cutaneous haemorrhages, which may prove 
fatal before other haemorrhages have had time to manifest 
themselves. It offers the worst prognosis of any form of 
purpura. 

Treatment. — In cases of simple purpura and the rheumatic 
forms in general, the best results will be obtained by prescrib- 
ing for the underlying constitutional condition. Such reme- 
dies as Bryonia, Ledum, Arnica, Hamamelis, Rhus tox. and 
Sulphur will suggest themselves. 

In the haemorrhagic form a different line of remedies is in- 
dicated. Crotalus, Lachesis, Kali hydrojodicum, Phosphorus, 
Rhus venenata, Secale, Sulphuric acid and Ledum are to be 
consulted as most homoeopathic to this condition. 



CHAPTER XVI. 

DISEASES OF THE NERVOUS SYSTEM. 

The investigation of the nervous system in children presents 
many difficulties. Not only is the child unable to express its 
sufferings or describe its condition with any degree of accu- 
racy, but we are confronted also with the task of differentiat- 
ing conditions arising out of purely reflex and transient (toxic) 
causes from those of a more serious and permanent nature. 

In many forms of disease the morbid condition becomes at 
once apparent, and we are enabled to study the pathological 
processes involved by direct observation. Cutaneous erup- 
tions, iritis, a broken bone — these are conditions which we 
can observe in a purely objective manner and at once recog- 
nize. In nervous diseases, however, the lesion is hidden, and 
a diagnosis can be made only by determining the nature and 
seat of this lesion by a process of deduction. Thus in our ex- 
amination we may find paralysis, atrophy, contracture, tremor 
or convulsion, and by studying these symptoms in conjunc- 
tion with the history and associated symptoms, we are fur- 
nished with the data for a diagnosis. 

This necessitates a careful study of every symptom in the 
case and a full recognition of its clinical significance, for in 
no other way can we reach a decision as to the character and 
location of the pathological process under consideration. 

Certain physiological peculiarities of the nervous system in 
infancy must be recalled in order to understand the meaning 
of some of its disturbances. Thus, the rapid growth and im- 
maturity of the brain predispose it to certain functional and 
inflammatory disturbances rare at a later period. The inhib- 
itory centres not being fully developed, and functionating 
only imperfectly, slight reflex iriitations which an older child 
would disregard are translated into motor or vasomotor dis- 



DISEASES OF THE NERVOUS SYSTEM. 439 

charges of more or less gravity. Again, slight organic lesions, 
bv reason of the secondary degenerative changes following 
them and the interference with the growth and development 
of adjacent parts at a time when the brain should be uni- 
formly and rapidly developing, leave behind them the most 
serious and ofttimes obscure consequences. 

An objective examination of the child may reveal abnormal- 
ities in the development of the body as a whole or only in 
certain parts. Thus, the head may be too large or too small, 
irregular in outline or abnormal in shape. Likewise, abnor- 
malities in the muscular system are readily noted — atrophy 
or hypertrophy ; paresis or paralysis of certain muscle-groups, 
with resulting deformity, or peculiarity of the gait; incoordi- 
nation of motion, tremor, localized or general convulsions, and 
choreiform movements. The state of the pupils and of the 
reflexes, and the presence of anaesthesia or hyperesthesia, 
are also of significance. 

The knee-jerk is best elicited by having the child in the 
dorsal position, with the heel resting upon the examiner's 
hand (Fig. 13). It is exaggerated in lesions affecting the 
upper neurons, i. <?., cerebral lesions. In lesions of the lower 
neurons, i. e., spinal cord and spinal nerves, it is diminished 
or abolished (poliomyelitis, diphtheritic paralysis). 

Kernig*s sign is found in meningitis (about 85 per cent, of 
cases), and at times in cerebellar haemorrhage and in lesions at 
the base of the brain. It is a phenomenon of hypertonia of 
the muscles. This condition was originally described as an 
inability to extend the leg upon the thigh when in the sitting 
posture, owing to tonic spasm of the hamstring muscles. 
When the dorsal decubitus is assumed, the leg can be straight- 
ened out, but if the thigh is now fixed upon the abdomen it 
again becomes impossible to straighten out the leg and a spas- 
modic resistence is noted in the contracted muscles. Fig. 46 
shows the most satisfactory manner of determining Kemig's 
sign. BabinskVs sign is an alteration in the type of response 
of the plantar reflex, there being hyperextensiorj of the great 



440 



DISEASES OF CHILDREN. 



toe instead of flexion. It indicates a disturbance in the 
pyramidal tracts. 

It must be remembered that the majority of brain lesions 
during infancy and early childhood are either cortical or bas- 
ilar. Haemorrhage into the internal capsule is rare, but oc- 
curs at times in syphilitic subjects. 

The function of the cranial nerves is determined in the 
manner employed for adults, as far as that can be carried out. 

Motor paralysis is detected by observing whether or not the 
child is able to move its extremities. Inability to walk may 
be due either to paralysis or to rickets (rachitic pseudo-paral- 




FlG. 46. — METHOD OF ELICITING KERNIG'S SIGN. 



ysis). In the latter case the child can move the legs, as tick- 
ling the sole of the foot will prove, but it is unable to stand 
or to walk. Spasticity, or u lead-pipe rigidity/' is found in 
cerebral palsies, usually in association with impaired men- 
tality. 

The mental development is difficult to guage in infancy. 
The early signs of subnormal intellectual capacity, or idiocy, 
are inability to support the head, amaurosis (amaurotic family 
idiocy), crying without cause, backwardness in grasping, in- 
ability to nurse properly. Later, the time when the child 



DISEASES OF THE NERVOUS SYSTEM. 441 

begins to walk and talk, affords important data, as well as the 
habits and disposition. Normally, a child should walk by the 
eighteenth month and begin to talk shortly after. According 
to West, a backward child would be normal were it of a 
younger age, while an idiot is abnormal for any age. 

Reaction of degeneration. By the "reaction of degenera- 
tion" is meant that series of phenomena which takes place in 
a muscle supplied with a motor nerve whose spinal ganglion 
cell has been destroyed, or, in fact, whose lower neuron has 
been affected at any point in its course. The reaction is dis- 
tinctive and differs so markedly from the reaction obtained 
by the galvanic current in a normal muscle that it serves as a 
ready and accurate diagnostic sign. 

Briefly stated, the muscle loses its irritability to the faradic 
current, while the contraction with the galvanic current be- 
comes slow and tetanoid in character, the main change, how- 
ever, being that it first responds to the anodal closure with a 
gradually increasing current instead of to the cathode, as oc- 
curs normally. The reaction of degeneration is found typically 
in poliomyelitis anterior. It also occurs in progressive muscu- 
lar atrophy and in multiple neuritis. 

By this method of examination the location of a lesion is 
ascertained, but its real character can at times only be defined 
by extending our researches back to the child's previous his- 
tory and to the family history. Knowing the prominent role 
played by such constitutional diseases as rickets, tuberculosis, 
syphilis and rheumatism in the etiology of nervous diseases in 
children, and the possibility of an identical clinical manifesta- 
tion resulting, e.g., from a tuberculous lesion in one case and 
from a syphilitic one in another, the importance of this mode 
of research becomes at once apparent. 

INSANITY. 

Insanity as a primary affection is rare during early child- 
hood, but at the period of puberty it readily occurs in the 
offspring of neuropathic parents. Traumatism, inflammatory 
29 



442 DISEASES OF CHILDREN. 

affections of the brain and other nervous diseases, such as epi- 
lepsy and hysteria, are causes next in importance to heredity. 
In young children a moral perversion may show itself as a 
result of deficient intellect, this, probably in all cases, being 
due to some actual physical defect in the child's brain or body. 

Children in whom the tendency to mental derangement is 
present are generally dragged, so to speak, into their insanity 
through mental overwork, grief, shame, excessive emotional 
excitement, maltreatment, masturbation and similar factors. 
In other words, as soon as a severe strain is brought upon the 
nervous system it gives way, and the child's mental instability 
becomes at once apparent. 

While insanity in children may assume a variety of phases, 
its manifestations cannot extend beyond the simplicity of the 
child's mentality. Juvenile insanity, therefore resembles the 
insanity of adults in every respect, excepting in that it is 
limited in its development. Again, certain forms of insanity 
observed in the adult are scarcely, if ever, observed during 
childhood. 

Moral insariity usually shows itself early, as it depends 
upon a deficiency in the entire intellectual sphere. The 
moral sense itself is deficient, and the general weakening of 
the intellectual faculties hinders the control of the immoral 
outbursts that is exercised to a greater or lesser extent by 
those of immoral tendency, but with good intelligence. If 
the immoral tendencies are sexual and pronounced already in 
childhood, Bayley, among others, recommends radical meas- 
ures, viz., unsexing the patient. Some writers of large expe- 
rience with this class of cases believe that the highest form of 
mental training offers a good chance of cure by developing 
inhibitory control. 

Mania may occur as a primary affection or be a symptom- 
atic accompaniment of epilepsy, hysteria or chorea. It may 
develop after typhoid fever. 

Epileptic insanity manifests itself as attacks of mania, with 
strong tendency to dementia or mental eufeeblement. 



DISEASES OF THE NERVOUS SYSTEM. 443 

Hysterical insanity presents that form of mental instability 
in which the emotional faculties are unduly and unrestrain- 
edly exercised, while there is a notable lack of will-power, 
which may culminate in outbursts of violence, accompanied 
by alternate sobbing and laughing, or it may appear as the 
graver psychoses represented by hystero-epilepsy and catalepsy. 

Melancholia is seldom seen before the eighth year, but it is 
a common form of the insanities among children. The same 
course is pursued as in adult cases. Both mental and physical 
depression, with self-persecution, characterize the condition. 
Attempts at suicide are not infrequent. The prognosis as to 
recovery is good, but a tendency to recurrence of insanity later 
in life is apt to persist. 

Periodic and circular insanity is almost unknown in chil- 
dren. In periodic insanity there are successive attacks of 
mania or melancholia, alternating, perhaps, with lucid in- 
tervals ; circular insanity is characterized by an alternation 
of maniacal and melancholic stages, followed by a lucid in- 
terval, with recurrence in the same or very rarely reverse 
order. 

Paranoia, primary delusional insanity, or progressive sys- 
tematized insanity, is a form of mental aberration of obscure 
and indefinite origin, gradually evolving with, the growth of 
the individual. 

In its fully developed state delusions of persecutions and 
grandeur are developed, existing as fixed ideas, which it is 
impossible to overcome or eradicate. Long before mental 
disease is apparent or suspected the paranoiac gives evidence 
of being odd or peculiar. Kraft-Ebing has observed that 
many cases of paranoia have shown strong evidence of mental 
instability in childhood. He could trace the incubation symp- 
toms back to the fourth year. These children are imaginative 
and dissatisfied with their home surroundings, believing 
themselves less favored than their brothers and sisters. They 
are given to day-dreaming and one of the first delusions nun- 
be that they imagine themselves to be the children of other 



444 DISEASES OF CHILDREN. 

parents — persons of higher social standing (Lehrb. d. Psychia- 
trie). 

Exclusiveness ; mental precocity in philosophical, religious 
and inventive directions ; irritability of temper and cruelty 
are signs offering a sad outlook for the child's future mental 
state, especially when they are encountered in a family with 
psychopathic tendencies. 

Dementia. — Paretic dementia is exceedingly rare during 
childhood ; however, such conditions as epileptic insanity 
and masturbation insanity, which are relatively common dur- 
ing childhood, show a strong tendency to terminate in de- 
mentia, thereby frequently leading to its development at a 
much earlier period than usual. 

Masturbation insanity is a form of mental disease in which 
masturbation exists as an uncontrollable condition, eventu- 
ally developing a complete intellectual breakdown. In spite 
of the best-directed efforts the habit can seldom be brought 
under control, the patient gradually degenerating into a state 
of idiocy or dementia. As the case progresses the habit is so 
engrafted upon the mind that it practically becomes a mental 
process, and all sorts of devices are utilized to evade detec- 
tion. It is not at all rare to find the habit already established 
long before puberty. A tendency to masturbate exists in all 
mental derangements in children, but never to such a pro- 
nounced degree as in this special form of disease. 

Night terrors and morbid fears are temporary mental dis- 
turbances in which hallucinations of various kinds are de- 
veloped in the child's imagination through fright, or through 
the suggestions resulting from the recital of ghost-stories and 
fairy-tales, or from vicious threats. The rational explanation 
for a large number of cases of frightened awaking from sleep is 
in my belief spasm of the glottis or some other form of respi- 
ratory obstruction coming on at night as a result of adenoids. 
As many children with adenoids present these symptoms the 
throat should always be examined in such cases. Another 
common cause of disorders of sleep is gastro-intestinal irrita- 



DISEASES OF THE NERVOUS SYSTEM. 445 

tion ; but in these the symptoms are reflex in character, and 
do not approach the nature of a psychosis, as do the above. In 
neurasthenia and lithsemia similar disturbances are observed. 
The idiopathic fears and terrors point to a highly neurotic 
form of constitution, and they may indeed be the forerunners 
of a more serious mental trouble. 

IDIOCY AND IMBECILITY. 

The term " feeble-minded " is employed to include all cases 
from the mere mentally backward down to the so-called im- 
becile or idiotic, the distinction being only one of degree. 
Imbecility denotes a lesser amount of mental incapacity than 
idiocy, which is thus defined by Ireland {Mental Affections of 
Children) : " Idiocy is mental deficiency, or extreme stupidity, 
depending upon masturbation or disease of the nervous 
centres, occurring either before birth or before the evolution 
of the mental faculties in childhood." 

In the etiology of idiocy hereditary transmission plays 
an important role ; of all mental derangements it is the 
one most frequently propagated by descent. A neuropathic 
family tendency ; parental imbecility or insanity ; consan- 
guine marriages ; the tuberculous diathesis ; drunkenness, 
and worriment or fright of the mother during pregnancy, are 
all well-established causes of idiocy. The lesions responsible 
for idiocy are either present at the time of birth, having de- 
veloped in utero, as in genetous idiocy, or the}' may develop 
late, as in the case of traumatic, inflammatory, epileptic and 
paralytic idiocy. The determinate causes or pathological 
conditions rendering the child idiotic are lack of development 
or of nutrition, or disease or injury affecting the brain either 
before or after birth. 

The following classes of idiocy are recognized by Ireland : 

Genetous idiocy, cases which cannot be traced back to any 
known specific disease, and whose pathology cannot be prop- 
erly diagnosed until after death. The condition of mental 
deficiency is complete before birth, and a neuropathic family 



446 DISEASES OF CHILDREN. 

history or some one of the conditions above mentioned is 
usually ascertainable to account for the direct hereditary 
transmission of the disease. 

An interesting developmental abnormality common in the 
subjects of genetous idiocy is the high-vaulted and narrow 
palate. The mental state of the idiot may be said to remain 
at the status of the infant, or very slowly move toward the 
maturer state of the adult, never, of course, attaining a high 
degree of perfection. 

The expression of the idiot is generally good-natured and 
confiding ; the head is not necessarily small, although irregu- 
larity of formation, flatness in the occipital region and a rapid 
slope of the clivus are often present. The early symptoms of 
genetous idiocy are constant sleeping in early infancy and 
absence of interest and attention to its surroundings, 
inability of the infant to suckle well, a feeble grasp, failure 
to react to sensory impressions and sight, and backwardness 
in walking and talking. The occurrence of such symptoms 
in the presence of a vitiated heredity should always arouse 
our suspicions. Genetous idiocy forms the largest class of 
all cases of idiocy, and the prognosis is better than in those 
cases in which the child has been born with full posses- 
sion of his brain-power, and has afterwards been deprived 
thereof. — (Langdon Down.) Varieties of genetous idiocy 
are the Mongolian type, so-called from the resemblance these 
children bear to the Mongolian race, and the amaurotic type, 
first described by Sachs. In the latter variety the infant is 
apparently healthy at birth, but in the couise of a few months 
it begins to droop and manifest signs of mental and physical 
breakdown, with amaurosis. The outcome is fatal. 

Microcephalic and hydrocephalic idiocy are foims of idiocy 
which are usually congenital, like genetous idiocy, although 
hydrocephalus, with its consequent baneful effect upon the 
intellect, may not develop until a later period. 

Eclampsic, epileptic and paralytic idiocy belong to the ac- 
quired forms of the disease, developing in association with 



DISEASES OF THE NERVOUS SYSTEM. 44-7 

other disorders of the nervous system. The first variety in- 
cludes those cases in which convulsions were prevalent dur- 
ing the dentition period, from which the child has recovered 
but the brain structure has not escaped permanent nutritive 
impairment. These cases are frequently mutes, or they are 
afflicted with speech impediments. 

Epileptic idiocy, as the name implies, is mental deficiency, 
resulting directly from epilepsy. As epilepsy is one of the 
commonest causes of idiocy and insanity, epileptics will either 
manifest idiocy if the mental faculties are early impaired, or 
epileptic dementia if the baneful influence be delayed beyond 
the period of childhood. 

Paralytic idiocy depends upon destruction of cerebral sub- 
stance from lesions which may have developed either before 
birth (congenital idiocy) or after birth (acquired idiocy). In 
these cases there is frequently sufficient asymmetry of the 
brain present to produce noticeable inequality of the skull. 
Hemiplegia, more or less complete, the arm usually more 
affected than the leg, diplegia, or simply paresis of certain 
muscles, and imbecility, are the accompanying conditions. 

Inflammatory idiocy includes those cases following menin- 
gitis or some of the infectious fevers (post-febrile insanity) 
and idiocy depending upon atrophy and hypertrophy of the 
brain, the result of inflammatory changes. 

Sclerotic idiocy presents sclerosis with atrophy of the brain, 
diffuse sclerotic changes, and glioma with sclerosis (WiL- 
marth, Alienist and Neurologist, Oct., 1890). As predis- 
posing causes are mentioned the tuberculous diathesis ; neuro- 
pathic heredity ; alcoholism. Accidents to the mother dur- 
ing pregnancy and traumatism to the child's head during or 
after birth are exciting causes. 

Syphilitic idiocy is not considered a very common form, 
and, when present, usually takes a downward course, placing 
it more closely with dementia than with idiocy. Without 
producing idiocy, however, syphilis not infrequently renders 
children backward both mentally and physically, as the phe- 
nomenon of infantilism so clearly demonstrates. 



448 DISEASES OF CHILDREN. 

Traumatic idiocy results from pathological changes in the 
brain, induced by a destructive injury. A certain amount of 
inflammatory action must always be taken into consideration 
in these cases, but the effects of the injury predominate over 
those of the inflammation. Naturally, a certain degree of 
relationship exists between the character of an injury or the 
location affected and the degree of idiocy to be anticipated 
therefrom. 

Idiocy by deprivation is that condition of mental inef- 
ficiency resulting from the absence of two or more of the 
special senses. In such a case the brain may be perfectly 
normal and the faculties unimpaired, but the unfortunate 
deprivation of both the sense of hearing and of sight through 
such diseases as ophthalmia and scarlet fever occurring at an 
early period of childhood will result in complete mental ob- 
tuseness unless proper educational training be instituted. In 
some instances children have been born deaf and blind. 

Deaf-mutism stands as an independent condition, the result 
either of an acquired deafness through scarlet fever, typhoid 
fever, meningitis (especially epidemic cerebrospinal menin- 
gitis) and otitis media, or as a congenital deafness, on account 
of which the child does not learn to talk. If acquired after 
the seventh year, the child usually escapes mutism. Acquired 
deaf-mutism has, therefore, no relation to idiocy, but congen- 
ital deafness is a common symptom of idiocy, simply indi- 
cating one phase of the hereditary nervous deficiency of 
genetous idiocy. Then, again, idiotic tendencies in a child 
are markedly increased by the absence of or obtuseness of 
any of the special senses, so that acquired deafness is a most 
serious calamity to befall a child of this stamp. 

Cretinism; Cretinoid Idiocy, or Sporadic Cretinism. — Cre- 
tinism is an endemic condition prevalent in certain moun- 
tainous regions of Europe, especially inclosed in valleys. 
The abnormal mental and bodily development is associated 
with goitre, and cretinism is only found where goitre is 
prevalent. The impaired function of the thyroid is accepted 
as the cause for these manifestations. 



DISEASES OF THE NERVOUS SYSTEM. 449 

The symptoms of cretinism are short stature ; mental de- 
ficiency : loose, flabby skin ; depression of the root of the 
nose and great distance between the eyes ; obtuseness of hear- 
ing or deafness, and goitre. 

Sporadic cretinism, or cretinoid idiocy, is a condition of 
myxcedema resulting from absence of the thyroid gland. This 
condition was first described by Fagge { Medico- Chimrgical 
Transactions, London, 187 1), and numerous cases have since 
been published both in America and Europe. 

The child may be born without a thyroid from embryonic 
degeneration of the same, or its degeneration may not begin 
until after birth. This has apparently resulted, in some in- 
stances, from an acute illness. 

The first symptoms to be noted are apathetic dulness and a 
large, thick tongue. These signs may show themselves in 
early infancy or not until the child is several years old. The 
growth becomes stunted, the hands and feet are short and 
stumpy, the skin loose and wrinkled ; temperattire subnormal, 
and the ossification of the cranial bones is delayed ; the head 
is large, fontanelles open, the nose flat and eyes widely sepa- 
rated, the enlarged tongue protrudes slightly from the mouth 
and the lips are thickened. Altogether they present a char- 
acteristic picture— a dwarfed, ugly, usually sluggish creature. 
The remarkable feature of this form of idiocy is the prompt 
improvement produced by thyroid treatment. 

The treatment of idiocy in general is one of training, which 
cannot be entered upon here. The child's health must be kept 
in the best possible state, and, as the unhampered action of 
the senses is most important, adenoids and enlarged tonsils 
must be removed when they interfere with hearing and nasal 
respiration. There are special schools where proper training 
of the intellect through the various senses is carried out. 
Public institutions are hampered by overcrowding. In some 
of the private schools the results obtained have been far be- 
yond expectation in many cases. 

Cretinoid idiocy is the only form in which positive results 



450 DISEASES OF CHILDREN. 

are to be expected from medicinal treatment. The dessicated 
extract of thyroid gland is administered in doses ranging from 
a half-grain twice daily in the beginning to one to two grains 
thrice daily later, in the absence of unfavorable symptoms. 
Relapses usually occur on discontinuing treatment. The con- 
fusion of cases of rickets with cretinism has led to the publi- 
cation of cures by other therapeutic means. 

For the various other forms of idiocy, constitutional treat- 
ment is often indicated, especially anti-tuberculous and anti- 
syphilitic treatment. Besides, such remedies as Baryta carb., 
Calc. phos., Aurum, Kali phos. and Sulphur undoubtedly exert 
a favorable influence upon the growth and mentality of back- 
ward and imbecile children, but, unfortunately, nothing very 
tangible can be expected. 

DISEASES OF THE BRAIN AND ITS MEMBRANES: 
ACUTE LEPTOMENINGITIS. 

Acute inflammation of the pia mater is in most instances 
secondary to some one of the infectious diseases, notably 
pneumonia, typhoid fever, scarlet fever and influenza. An 
unquestionable relationship seems to exist between many 
cases of meningitis and entero-colitis, the so-called metas- 
tasis of the latter condition to the brain, observed by 
our older clinicians, being explained by the possibility of 
infection of the meninges with pathogenic bacteria from the 
alimentary tract, or by the direct action upon the brain of the 
toxines generated there. Beside these causes, traumatism, 
sunstroke and acute nephritis also may induce a meningitis, 
and suppurating otitis media, erysipelas of the scalp and ab- 
scess of the brain are dangerous in that they invite extension 
of the infection to the meninges. 

The epidemic variety of meningitis, usually described as 
cerebrospinal meningitis or spotted fever, from involvement of 
the meninges of the cord and the appearance of an exanthem 
during its course, is of infectious origin, the diplococcus intra- 
cellularis meningitidis of Weichselbaum being the specific 






DISEASES OF THE NERVOUS SYSTEM. 451 

micro-organism (see "Acute Infectious Diseases"). Purulent 
meningitis from infection with the pneumococcus may also 
develop at times apparently primarily. 

The pathological changes observed in the brain of children 
dying of meningitis vary with the severity of the case and 
stage at which a fatal termination took place. Frequently 
nothing more is found than intense hyperaemia and cedema- 
tous infiltration of the pia matei. Such cases run a rapid 
course, and the diagnosis is frequently not made intra vitam. 
When, however, the onset has been more gradual and the dura- 
tion longer, large flakes of fibrin and islands of purulent exu- 
dation are found covering the convexity of the brain and 
filling-in the convolutions, notably over the anterior lobes. 
In many instances the membranes of the cord are simultane- 
ously involved, notably over its posterior surface. This in- 
volvement is especially marked in the epidemic variety and 
in purulent meningitis with spinal symptoms. 

The symptomatology of acute leptomeningitis points to in- 
volvement of the convexity of the brain as a predominating 
condition. It is most common in infants, in whom it may 
develop idiopathically, or in conjunction with an entero- 
colitis or broncho-pneumonia. I recently saw such a case, 
which was undoubtedly toxic in origin, the autopsy revealing 
a large caseous mass in the stomach consisting of a conglom- 
eration of bread and milk. During the course of an appar- 
ently simple gastro-enteritis this infant was suddenly seized 
with convulsions and rapidly-rising temperature, death result- 
ing within twenty-four hours, from meningitis. 

There is always danger of meningitis in cases of purulent 
otitis media in which, owing to the proximity of the dura mater 
to the seat of the pus, the thinness of the temporal bone and 
the channels of communication existing in childhood between 
the dura and the middle ear. For this reason acute purulent 
meningitis, cerebral abscess and thrombosis of the jugular 
bulb must always be borne in mind as possible complications. 

Infantile acute leptomeningitis may not be suspected until 



452 DISEASES OF CHILDREN. 

convulsions set in, but in many instances the child will pre- 
sent definite symptoms pointing to the beginning of a menin- 
geal inflammation, viz.: bulging of the fontanelle ; malaise ; 
elevation of temperature ; irregular or contracted pupils ; 
strabismus ; projectile vomiting and rigidity of the cervical 
muscles. As the case progresses, coma ; dilated pupils ; con- 
vulsions, and death or ultimate recovery, with impairment of 
the special sense, may ensue. 

The meningitis occurring later in childhood is almost in- 
variably secondary to an infection or septic condition 
with the exception of the epidemic form of cerebrospinal men- 
ingitis, and tuberculous meningitis, the later variety, of course, 
being in many instances but the terminal event in a more or 
less general tuberculosis (see Tuberculous Meningitis). A 
secondary meningitis is naturally masked more or less by the 
disease which it accompanies, and if the lesions are confined 
solely to the convexity it is difficult of recognition, as the 
symptoms of stupor, delirium, convulsions, dilated pupils, 
irregular respiration, irregular and slow pulse and vomiting 
might be attributed to the original disease. Unless occurring 
in children over two years old, the characteristic slowing of 
the pulse and the Cheyne-Stokes respiration may be poorly 
developed, although the majority of cases I have seen even in 
infants presented this symptom. Meningitis as a complication 
of another acute illness becomes a serious matter, death 
supervening, within a few days of the onset in convulsions 
or coma, the temperature often running very high. If the 
process has extended to the base and into the spinal canal, 
there will be added opisthotonos ; strabismus ; deafness and 
cutaneous hypersesthesia. 

The prognosis of meningitis is always grave. It is con- 
ceivable that mild cases, such as may accompany broncho- 
pneumonia, entero-colitis, or result from traumatism, fre- 
quently recover, but the question of a correct diagnosis arises 
here. The likelihood of idiocy and permanent sensory and 
motor defects remaining after meningitis should not be lost 
sight of. 



DISEASES OF THE NERVOUS SYSTEM. 453 

In the diagnosis of meningitis the only positive signs are 
those indicating actual compression or continued irritation 
of the cerebral structure, manifesting themselves as con- 
tracted, and, later, dilated, pupils ; ccular palsies ; opisthot- 
onos ; coma ; projectile vomiting ; headache ; high fever, 
with irregular and slow pulse, and irregular breathing and 
localized paralyses or convulsions. Although such symptoms 
as progressive prostration ; elevated temperature ; bulging of 
the fontanelle ; squinting ; projectile vomiting and convul- 
sions are strongly suggestive of meningitis, still they may all 
be induced by even harmless ailments which have no connec- 
tion at all with meningitis, being purely toxic and coming 
under the category of "teething," "reflex irritation," 
"worms," and the like, or marking the advent of some acute 
illness. Cerebral symptoms coming on suddenly and accom- 
panied by high fever are toxic in origin with greater likeli- 
hood than inflammatory. They usually pass off in the course 
of a few days — with the crisis of a pneumonia ; after empty- 
ing the bowels in an acute gastro-intestinal intoxication or 
with the appearance of the rash in an exanthem. On the 
other hand, cerebral symptoms coming on insidiously or ap- 
pearing in the later stages of an attack of pneumonia, influ- 
enza, ileo-colitis, are of graver import, and as a rule prove to 
be due to meningitis. In autointoxication there is absence of 
high fever and diacetic acid and acetone may be found in the 
urine. Urcsmia and diabetic coma must also be thought of. 

TUBERCULOUS MENINGITIS ; BASILAR MENINGITIS. 

Tuberculous meningitis is often spoken of as basilar men- 
ingitis on account of the constancy with which the tubercu- 
lous lesions develop at the base of the brain, they, only in 
exceptional instances, involving the convexity, and then as 
an extension of the process from the base. The opposite con- 
dition holds good in simple meningitis ; but all cases of basi- 
lar meningitis are not necessarily tuberculous, some being of 
syphilitic origin and others a primary infectious disease ex- 



454 DISEASES OF CHILDREN. 

isting without the presence of any inflammatory lesions else- 
where excepting an exudative process about certain tendon- 
sheaths. This form of meningitis (posterior basic menin- 
gitis) is not uncommon in infants, and is frequently con- 
founded with tuberculous meningitis. Still {The Micro-Or- 
ganism of Simple Posterior Basic Meningitis in Infants, 
Trans. Brit. Med. Ass., 1898) has demonstrated a diplococats 
in these cases. Koplik (Amer. Jour. Med. Sciences, Feb., 
1905) finds that the cases described by Still, while usually 
sporadic, also occur during epidemics of cerebrospinal men- 
ingitis and are due to the meningococcus intracellulars. 
Koplik describes a variety occurring in older children which 
may be complicated with pneumonia or be secondary to the 
same. 

Tuberculous meningitis is by no means a rare disease. It 
is quite common for children of the tuberculous diathesis to 
become thus affected, and the victims of general tuberculosis 
frequently die of a terminal meningitis. This is especially so 
during infancy, while in older children the meningitis may 
exist as an apparently primary condition ; but even here an 
autopsy usually reveals unsuspected tuberculous lesions of 
the internal viscera. Tuberculosis of the bones and lymphat- 
ics is also a strong predisposing factor to tuberculous menin- 
gitis. Heredity plays an important role, and in certain fami- 
lies the disease appears with appalling regularity. Further- 
more, all conditions favoring or resulting in malnutrition 
offer a predisposition to the disease. 

Primary meningitis in infants is most often tuberculous. 
The tubercle bacilli may gain access to the meninges through 
the nose by means of the vein of Zuckerkandl or through a 
necrosed cribriform plate. I had under my observation an 
infant in whom tuberculous meningitis followed upon an 
attack of purulent coryza that was treated with injudicious 
local applications and probing. 

The pathological changes found in the brain are miliary 
tubercles situated along the course of the blood-vessels at the 



DISEASES OF THE NERVOUS SYSTEM. 455 

base of the brain, chiefly following the sylvian artery ; in- 
flammatory reaction in the pia with the production of 
lymph- and pus-cells, and exudation into the ventricles 
(acute hydrocephalus), and more or less infiltration of the 
brain substance (meningo-encephalitis). The blood-vessels 
are injected and bathed in a sero-gelatinous exudate. In the 
advent of much effusion the convolutions appear flattened, 
but the amount of effusion and exudation seen in simple men- 
ingitis is rarely present. Ordinarily the eruption of tubercles 
is limited to the base, for which reason tuberculous menin- 
gitis is also known as basilar meningitis, but tuberculous 
deposits may also occur in atypical localities producing focal 
symptoms — cerebral tuberculosis — or these deposits may 
simply accompany basilar meningitis as an encephalitis. 
The clinical manifestations depend upon the direct pressure 
of the tuberculous deposit upon the cranial nerve roots at the 
base of the brain as well as upon increased weight of the 
brain and intracranial tension from the exudation of serum. 
The meninges of the cord at its site of origin are almost in- 
variably involved ; this is the cause of the retraction of the 
head characteristic of the disease. 

Symptomatology. — For physiological reasons the symp- 
toms will vary with the age of the child. This also modifies 
the clinical course of the disease to a certain extent, as tuber- 
culous meningitis is often but the terminal event of a more 
or less general tuberculosis. There is, however, a sufficiently 
large number of cases of tuberculous meningitis occurring 
without demonstrable evidence of pre-existing tuberculosis to 
justify us in suspecting every primary meningitis in a young 
child, in the absence of an epidemic of cerebro-spinal fever, 
as being tuberculous. 

The characteristic slowing of the pulse and the disturbed 
rhythm of the respiratory act are generally not observed until 
after the second year, as the inhibitory centres are not fully 
developed until this time. So also, intellectual and sensory 
disturbances cannot be obtained until the child's brain is 
correspondingly developed. 



456 DISEASES OF CHILDREN. 

A typical case pursues the following course: For a few 
weeks the child manifests signs of indisposition and malaise. 
It loses interest in its games and associates, the appetite fails, 
and emaciation and progressive anaemia become noticeable. 
There is constipation, and at times a slight elevation of tem- 
perature. As the cerebral lesions become of sufficient promi- 
nence to produce specific symptoms, headache, vomiting and 
slowing of the pulse develop. They constitute the main 
symptoms of the first period of the actual meningitis, or the 
stage of cerebral irritation. Together with slowing and irreg- 
ularity of the pulse there is irregularity in the respiratory 
rhythm, later on approaching the Cheyne-Stokes type of 
respiration. 

Constipation is present from the beginning, the abdomen 
being flaccid, and in some instances noticeably retracted. 

Vomiting is usually of the projectile type, after which the 
child seems weak and apathetic, gradually going into a state 
of stupor in the later stages. The vomiting results from irri- 
tation of the sensory meningeal branch of the vagus. 

Vasomotor disturbances present during this period are 
alternate flushing and paleness of the face, and the tache 
cerebrate, a broad, red line produced by drawing the finger- 
nail across the skin of the abdomen, persisting for a few min- 
utes and indicating vasomotor paresis. Irregular innervation 
of various muscles supplied by the cranial nerves is also a 
common symptom of this stage. To these manifestations 
strabismus and twitching of the facial muscles belong most 
prominently. There is ptosis and the eyes are often fixed in 
a characteristic vacant stare. The accumulation of fluid in 
the ventricles is largely responsible for the pressure symptoms 
upon the centres of the oculo-motor nerve. Likewise, the in- 
creased weight of the brain causes it to sag down upon the 
base of the skull and, by direct pressure upon the abducens, 
set up an inward deviation of the eyes. The deposit of mili- 
ary tubercles and inflammatory exudate upon the basal nerve 
roots tends to produce paralysis in the parts supplied by them. 



DISEASES OF THE NERVOUS SYSTEM. 457 

As the vagus and glosso-pharyngeus become involved death 
is the inevitable result. 

Retraction of the head, opisthotonos, rigidity, twitching 
and automatic movements of extremities belong to the spas- 
modic manifestations of tuberculous meningitis. The most 
characteristic of these is the retraction of the head, which is 
a strong presumptive sign of basilar meningitis, although it 
is frequently seen in toxaemia. We must also bear in mind 
that rigidity of the neck need not be continuously present 
during the course of the illness, and I have seen cases where 
it was either altogether absent or only slightly developed. 

In infants emaciation is pronounced and progressive. Con- 
vulsions may occur, but they are not a constant feature. 
Likewise, the shrill, piercing cry, "cri hydrocephalique," may 
or may not be heard. 

The case now gradually goes over into the second period, 
that of paralysis. The duration of the first period is variable, 
the average being from ten days to two weeks. Its course is 
also irregular, unexpected signs of improvement frequently 
showing themselves, from which the child soon lapses back 
into its original state. 

The second period is characterized by progressively increas- 
ing stupor, increased frequency of the pulse and failing heart, 
dilatation of the pupils, opisthotonos with general relaxation 
of the muscles of the extremities in which transient convul- 
sive movements .may be noted, complete coma and death. 
Although the temperature is not high during the course of 
the disease, unless an associated tuberculous process renders 
such the case, still there may be a rapid rise shortly before 
death, which may attain to a high degree of hyperpyrexia. 
Death in convulsions is not common. The average course is 
from two to three weeks, not including prodromal symptoms. 
A case of meningitis living beyond six weeks may safely 
be looked upon as non-tuberculous. 

The prognosis is always unfavorable. I have seen a few 
apparently genuine cases recover, but I doubt if they will be 
30 



458 DISEASES OF CHILDREN. 

spared a relapse or death from general tuberculosis at some 
later period, if they really were tuberculous. Unfortunately, 
an absolutely positive diagnosis cannot always be made, which 
leaves room for doubt in those cases going on to recovery. 
The toxic cerebral symptoms developing during pneumonia 
in childhood so closely resemble tuberculous meningitis in 
many of its phases that it really becomes difficult at times to 
estimate their true significance. They are certainly within 
the reach of our remedies, as I have repeatedly satisfied my- 
self, but the remedies which control them fall short in the 
true tuberculous process. 

The diagnosis of tuberculous meningitis is based upon its 
gradual onset, the presence of the tuberculous diathesis or 
tuberculous family history, and the development during the 
first period of the characteristic symptoms, namely, constipa- 
tion, headache, slowing of the pulse, vomiting and drowsiness. 
Later the condition becomes unmistakable, but in the early 
stages we must exclude the acute infectious diseases or acute 
gastritis with cerebral symptoms. 

Simple meningitis is differentiated by its rapid onset and 
acute course ; cerebral hypercemia by its transitory nature 
and hydro cephaloid by its association with diarrhoeal or other 
exhausting diseases. The last-named condition is described 
in another chapter. {Diseases of the Intestines, p. 206.) 

The positive recognition of meningitis is made possible by 
means of lumbar puncture. This procedure not only verifies 
the diagnosis of meningitis, but enables us at the same time 
to recognize its true nature, i. e., whether tuberculous or 
purulent. 

LUMBAR PUNCTURE. 

Lumbar puncture was introduced by Quincke as a method 
of diagnosis in intracranial affections and its value in this di- 
rection is now firmly established. Besides it has also attained 
to some extent the role of a therapeutic agent. Owing to 
the continuity of the sub-dural space throughout the entire 



DISEASES OF THE NERVOUS SYSTEM. 4r59 

cerebro-spinal nervous system, it is self-evident that a speci- 
men of fluid withdrawn from the lower end of the dural sac is 
identical in character with the fluid high up in the spinal canal, 
and even within the cranium. Clinical experience has proven 
this to be true so regularly that now we are in a position to 
learn the nature of an intracranial effusion or accumulation 
with practical certainty. Furthermore, by means of a canula 
inserted into the spinal canal we can estimate the intracranial 
pressure as readily and accurately as, for example, we esti- 
mate the blood pressure in the peripheral arteries. 

Before entering into a discussion of the character of the 
cerebrospinal fluid under normal and abnormal conditions, it 
will be well first to describe the technique of performing 
lumbar puncture. 

We nnist remember that the spinal cord proper terminates 
in the conus at the second lumbar vertebra, where it divides 
into two coarse strands of fibres, which hug the lateral walls 
of the spinal canal. These bundles constitute the cauda equina 
and there is plenty of space between them for the safe intro- 
duction of a canula ; besides, they are more or less movable 
and therefore not readily wounded. 

If, therefore, we introduce a small trocar between the spines 
of the third and fourth or fourth and fifth lumbar vertebrae, 
we enter the dural sac most satisfactory for the purpose of 
aspiration. 

The best instrument to use is the original Quincke needle, 
which is made by Tiemann & Co., after a pattern brought 
to this country by Koplik. An aspirating needle — 10 cm. 
long and i mm. in diameter — answers in the case of children, 
but a small trocar will be found more convenient to handle. 
The operation must be performed under the strictest asepsis ; 
this applies to the operator's hands, the instrument, and to 
the skin at the site of puncture. vScrubbing with soap and 
water, followed by the use of alcohol and lastly a i-iooo so-' 
lution of bichloride is to be recommended. 

It is by no means easy to locate the different vertebra: by 



460 DISEASES OF CHILDREN. 

attempting to count them from above downward, but if w T e re- 
member that a line drawn across the back on a level with the 
crests of the ilia will intersect the fourth lumbar interspace, 
it is a simple matter to select either this space or the one above 
it as the site for puncture. We may puncture as high as the 
second interspace, but there is not only an imaginary, but an 
actual advantage in selecting the lowest point, for as Sahli was 
able to demonstrate, pus and other elements tend to gravitate 
to the lowest point, and w 7 hen present in inconsiderable 
amount, clear fluid may be withdrawn from the second, while 
a cloudy one may come from the fourth interspace. 

The patient is laid upon the right side, and the spinal col- 
umn bowed as much as possible by flexing the legs upon the 
abdomen and pressing down upon the buttox, at the same time 
bending the upper portion of the back by downward pressure 
upon the shoulders. Care should be exercised not to exert 
pressure upon the neck, but always upon the shoulders. The 
spines of the vertebrae now stand out prominently and we are 
in a position to plunge between them into the canal. When 
the patient is comatose no anaesthetic is required, and when 
partly conscious ethyl chloride should be used locally. In 
young children the laminae of the vertebrae are horizontally 
placed and the interspinous ligament is not very firm. For 
this reason we can pierce directly between the spines and enter 
at a right angle to the spinal column. In older children the 
laminae are somewhat overlapping and the interspinous liga- 
ment is tough and firm. Here it is best to pursue the course 
first recommended by Quincke, namely, place the point of the 
needle to the lower side of the median line and a little below 
the interspace ; then pierce upward and inward, thus avoiding 
the ligament and at the same time slipping in between the 
laminae. In a child two years old the dural sac is penetrated 
when the needle is inserted for a distance of from 2 to 3 cm., in 
adults it must penetrate 4 to 6 cm. With a little practice we 
soon learn to recognize when the needle is in the spinal canal ; 
there is no further resistance and the point can be freely 



DISEASES OF THE NERVOUS SYSTEM, 



461 



moved. The stilet of the trocar is now removed and the first 
few drops of fluid are allowed to flow out ; the remainder is 
caught in a sterilized graduate, in order to estimate the quan- 
tity withdrawn. Ten cc. is sufficient for diagnostic purposes, 
but when the pressure is great we may withdraw as much as 
fifty cc. A portion of this can be used for making cultures 





PIG. 47. — METHOD OF PERFORMING LUMBAR PUNCTURE. 

or for inoculating guinea pigs. The balance is studied macro- 
scopically and microscopically. The chemical examination 
is also important. 

The study of intracranial pressure is interesting, but of lit- 
tle clinical value in pediatric practice. For practical pur- 
poses we can estimate this sufficiently by the force with which 



462 DISEASES OF CHILDREN. 

the fluid flows from the canula. If a manometer be attached 
to the canula the pressure can be measured in mm. of mer- 
cury. The normal pressure in adults in the prone position is 
5 to 7.3 mm. Hg.; a pressure above 15 mm. Hg. is indicative 
of conditions such as meningitis and brain tumor (Sahu). 
Koplik gives the pressure as from 5 to 35 mm. of mercury. 
It is lower in children than in adults. 

Under normal states of pressure the fluid comes from the 
canula drop by drop. When the pressure is increased the 
drops come more rapidly and with considerable effusion it 
will spurt out in a stream. The stream is not steady and is 
affected by respiration. It is interesting to note the immedi- 
ate amelioration of symptoms when such pressure is relieved, 
but unfortunately this improvement is but temporary in the 
majority of instances. In young infants the fontanelle offers 
an additional means of estimating intracranial tension. 

The normal cerebro-spinal fluid is clear, colorless and 
limpid. Its specific gravity is very little above that of water, 
from 1003 to 1005. Besides a low percentage of albumen 
(less than ^ per cent.; Lenhartz), it contains a trace of 
sugar and salts. Alfred Hand (Phila. Med. Journal, Aug., 
1902), found from 0.5 to 1.9 per cent, albumen by bulk with 
the potassium ferrocyanid test, while in ordinary meningitis 
there will be from 4 to 5 per cent, and in tuberculous menin- 
gitis it ran as high as 16 per cent, in one of his cases. 

Absence of sugar speaks for ordinary meningitis, while its 
presence favors a tuberculous condition (Hand). 

The admixture of blood may be due to the wounding of a 
vein and rather spoils the specimen for gross and microscopic 
study. It may, however, throw light upon the diagnosis when 
haemorrhage into the cord or ventricles is suspected. 

In tuberculous meningitis the fluid is usually but a trifle 
cloudy ; in fact, it may require close inspection in a good light 
before we will recognize a slight turbidity. Such fluid should 
be placed in a conical sediment glass in a refrigerator for 24 
hours, at the end of which time a delicate mesh-work of spon- 



DISEASES OF THE XERA T OUS SYSTEM. 463 

taneously coagulated fibrin will have formed. Toward the 
latter part of the disease the fluid becomes more cloudy. 

In epidemic cerebrospinal meningitis the fluid may be clear 
in the early stage, but later it becomes purulent. The same 
may be said of the other forms of meningitis, usually second- 
ary — in the early stages of which there may be clear fluid 
with suspended flakes of fibrin, just as we see within the 
cranium — later becoming creamy or admixed with blood. 

In hydrocephalus the fluid is clear, although it contains 
some leucocytes. 

The cellular elements of the cerebro-spinal fluid are of defi- 
nite significance. As in any other pyogenic infection the ex- 
udate consists chiefly of poly nuclear leucocytes in suppurative 
meningitis. This also holds good in meningitis due to the 
pneumococcus, and the epidemic variety due to the meningo- 
coccus intracellularis of Weichselbaum. 

French writers lay great stress upon the predominance of 
lymphocytes in tuberculous meningitis. While the value of 
cytodiagnosis in cerebral inflammations is not without limi- 
tations, still a marked increase in lymphocytes over polynu- 
clear elements is strong presumptive evidence in favor of a 
tuberculous infection. Osier states that in his recent cases 
he was not able to verify these claims and it is quite true that 
the lymphocyte count is subject to a wide range of variations. 
Thus, Hand found in a case of tuberculous meningitis that 
one tapping gave 35 per cent., while a subsequent one gave 
85 per cent, lymphocytes. A persistent excess of polynuclears 
seems to rule out a tuberculous infection with more or less 
certainty. Again, the number of tubercle bacilli present seem 
to bear a direct ratio to the number of lymphocytes that will 
be found in the specimen. 

In purulent exudates ordinary cover glass preparations 
stained with methylene blue are sufficient for the study of 
the bacteria present. Streptococci and pneumococci are 
recognized by their morphology while the micrococcus of 
epidemic cerebro-spinal fever is a diplococcus similar in ap- 



464 DISEASES OF CHILDREN. 

pearance to the gonococcus. The majority of these diplo- 
cocci will be found within the pus cells. As Park puts it, 
the cells are crowded with the diplococci. The differentia- 
tion between meningitis due to this diplococcus and that due 
to pneumococci or streptococci is of great clinical value, as 
forty per cent, of the former cases get well, while almost all 
of the others die. 

Tubercle bacilli are as a rule present in scant numbers, but 
if we allow the fluid to stand for twenty-four hours, the bacilli 
and cellular elements will become entangled in the mesh- 
work of fibrin, which has formed at the end of that time. 
The fluid can then be centrifuged and the sediment stained 
for tubercle bacilli in the usual manner. By this method 
their demonstration becomes successful in the majority of 
cases. 

The indications for the lumbar puncture are any obscure 
cerebral condition in which there is clinical evidence of in- 
flammation of the meninges or the presence of an exudate, 
whether it may be serous, purulent or hemorrhagic. 

So far its chief value has been that of a diagnostic aid, the 
importance of which cannot be questioned. Temporary re- 
lief of symptom, coma, convulsions, has also attended its use, 
and in the control of uraemic convulsions and coma it has 
proven of value. Complications, such as pneumonia, contra- 
indicate it. When carried out lege artis, and for a definite 
purpose, lumbar puncture is not only justifiable, but abso- 
lutely essential to the scientific practitioner. 

Treatment. — The general management of cases of acute 
leptomeningitis and tuberculous meningitis differs somewhat, 
owing to their clinical diversity. Leptomeningitis runs an 
acute course and frequently exists as a complication of an- 
other acute illness, for which reason it becomes more difficult 
to manage than the subacute tuberculous type. Hyper- 
pyrexia may be present, necessitating frequent sponging, and 
the occurrence of convulsions calls for a warm bath in in- 
fants or a warm pack in older children. Should these mani- 






DISEASES OF THE NERVOUS SYSTEM. 465 

fest a tendency to recur or become persistent, a hot mustard 
pack is more efficient. Stimulation may become necessary 
in the later stages. The ice-cap is recommended by some, 
but I doubt its efficacy. 

In tuberculous meningitis, prophylaxis offers the only 
promising results. Aside from a low diet, attempts at keep- 
ing the bowels open by means of enemata and the employ- 
ment of simple dietetic measures, beside stimulation when 
indicated, there is little to be done with the exception of 
what medicines may accomplish. 

Aeon, may be indicated early in primary cases of lepto- 
meningitis. 

Apis. — This is one of the most important remedies in 
meningitis, both the subjective symptoms, as well as the 
pathological tendency of the drug, indicating it in many in- 
stances. Particularly characteristic of Apis is the shrill, 
piercing cry, which is usually heard at night, while the child 
is asleep or in a soporous condition. Other prominent symp- 
toms are difficulty in swallowing ; retraction and rolling of 
head ; strabismus and dilated pupils ; gritting of the teeth ; 
suppressed urine ; convulsions and coma. The amount of 
effusion is usually considerable in cases calling for Apis. 

Arnica is recommended in traumatic cases. 

Bellado7tna presents a true picture of the early stages of a 
meningitis, at which time cerebral hyperaemia is the most 
prominent condition. It is of little use after effusion and 
exudation have taken place. The face is flushed ; eyes 
bright with dilated pulpils ; there is pronounced hyperes- 
thesia of the senses with frequent starting, especially on at- 
tempting to go to sleep ; the pulse is full and bounding, the 
fontanelle prominent, and general covulsions set in. 

Bryonia corresponds to the exudation stage. Fever with 
great thirst; and dryness of the skin and mucous membranes; 
irritability of temper with marked indifference and desire to 
remain quiet ; prostration ; constipation ; bursting headache ; 
face dark red ; head retracted ; constant chewing motion of 
mouth. 



466 DISEASES OF CHILDREN. 

Cicuta. — For the irritative stage of meningitis Cicuta is a 
most valuable remedy, particularly when there are general 
convulsions, beginning with twitching in the fingers and end- 
ing in complete unconsciousness. There is rolling of the 
head ; fixation of the eyes ; boring of the occiput into the 
pillow. The child is greatly agitated, grasping at its mother 
in a frightened manner when being taken up. 

Cuprum. — Especially useful during the exanthemata, 
after recession of the eruption. (Zincum, " not able to de- 
velop exanthemata.") The Acetate of Copper was first recom- 
mended by Dr. George Schmid, of Vienna, for the cerebral 
symptoms resulting from the retrocession of any of the acute 
exanthemata, or from difficult dentition, in cases not active 
enough for Belladonna (Hughes, Pharmacodynamics). 

Gelsemium may be indicated upon its well-known symp- 
toms of drowsiness, paralysis of the muscles of the eye, con- 
vulsive movements during sleep, intense headache and low 
form of fever. 

Glonoin. — Intense cerebral congestion, throbbing carotids, 
high arterial tension ; high fever, with paleness of face or in- 
tense redness. Veratrum viride is indicated in similar cases, 
where the symptoms are intense, Glonoin suits most partic- 
ularly the form of meningitis developing after sunstroke. 

Helleborus. — Exudative stage. Great irritability, eyes roll- 
ing from side to side, wrinkling of the folds of the forehead 
as if frowning, chewing motion of the mouth, boring the head 
into pillow, cervical opisthotonos, automatic movements of 
one or more of the extremities with jerking and twitching of 
groups of muscles; scanty, dark-colored urine with sediment 
like coffee-grounds. 

Kali hydrojodicum has been used with apparently some 
success to absorb the effusion. It is more particularly adapted 
to the epidemic variety of meningitis, in which cases, as a 
matter of fact, more can be done than in the other forms of 
meningitis. It is generally used in appreciable doses. 

Mercurius. — Intense headache, as if compressed by tight 



DISEASES OF THE NERVOUS SYSTEM. 4-67 

band. The child is drowsy, cries out in its sleep and tosses 
about restlessly. There may be a clammy offensive sweat, 
foul odor from mouth, thickly-coated and swollen tongue. 
Mercury is one of the most useful remedies to remove the in- 
flammatory exudate. 

Opium. — Sopor; pupils contracted or immovably fixed, with 
glassy, half-closed eyes and pale face ; stertorous breathing. 

Stramonium. — Violent delirium ; face red and bloated, with 
wild expression of eyes; automatic movements of hands and 
feet, convulsions and coma. Child awakens from sleep scream- 
ing and terrified. 

Sulphur. — On account of its pronounced absorptive action 
Sulphur is frequently indicated in the later stages of menin- 
gitis, especially when the case comes to a standstill. Many 
of its characteristic symptoms are frequently present in these 
cases, but even without such the above condition fully justifies 
its use. 

Zincum. — Continuous movement of the lower extremities, 
particularly the feet ; profound nervous depression, abolition 
of reflex action ; meningitis developing with the exanthemata 
or during an epidemic of such, when the rash recedes or does 
not make its appearance. 

In tuberculous meningitis Iodoform, Lycopodium, Calc. carl?., 
Calc. phos., Spongia, Apis and Sulphur seem most applicable. 
The alleged efficacy of Iodoform has attracted considerable 
attention of late. Several cases have been reported cured, 
both by the internal administration of the drug in the 2x to 
6x trit. and by the use of an Iodoform salve as an inunction, 
after shaving the scalp (Bailey, Medical Counselor, June, 
1898). I have in several instances relieved meningeal symp- 
toms accompanied by retraction of the head, occurring during 
the course of acute pulmonary affections, and in one case in a 
syphilitic infant, with this drug, but they were most probably 
of toxic origin. The provings of Iodoform contain many 
symptoms strongly suggesting its use in meningitis (see Cy- 
clopes di a of Drug Patlwgenesy, vol. iii). 



468 DISEASES OF CHILDREN. 

Lycopodium is well adapted to many cases coming on insid- 
iously in strumous children. Goodno {Practice of Medicine) 
reports such a case cured by Lycopodium 6x. 

Spongia is of great importance on account of its relation- 
ship to scrofulosis and tuberculosis (Hering). Its chemical 
composition would suggest a similarity with Iodoform. 

HYDROCEPHALUS. 

Hydrocephalus is a chronic idiopathic disease, in which 
there is an excess of serum in the cranial cavity (hydrops 
cerebri). The so-called acute hydrocephalus is in reality 
tuberculous meningitis. 

There are two forms of chronic hydrocephalus, namely, ex- 
ternal hydrocephalus and internal hydrocephalus. The former 
consists in the accumulation of serum between the dura mater 
and the arachnoid. It is rare, almost invariably occurring 
secondarily to a congenital defect of the brain, meningeal 
haemorrhage, pachymeningitis, or atrophy of the brain. In 
the last instance the serous effusion occupies the space left 
vacant by the deficient brain, and it is spoken of as hydroceph- 
alus ex vacuo. External hydrocephalus is also encountered 
congenitally. When not associated with a hopeless intra- 
cranial condition it presents the best prospects for cure by 
operative measures. 

Chronic Internal Hydrocephalus is the commonest form of 
the disease, and in speaking of hydrocephalus this is the 
variety usually implied. The largest number of cases are 
congenital. The head may be so large at full term as to im- 
pede delivery, or the effusion be but trifling and accumulate 
so slowly that the head does not become noticeably enlarged 
until several weeks after birth, making it difficult to deter- 
mine whether the case was congenital or acquired (Miles). 
Again, the child may be perfectly healthy at birth and during 
the early months of infancy, no enlargement of the head oc- 
curring until the fourth month, or even later. 

Internal hydrocephalus is almost invariably a primary con- 



DISEASES OF THE NERVOUS SYSTEM. 469 

dition. In rare instances it is found associated with tumors 
or inflammatory processes at the base of the brain when such 
conditions cause obstruction of the foramen of Magendie or 
obliterate the communications between the ventricles of the 
brain. Accumulation of cerebro-spinal fluid in the ventricles 
may result from diminished resistance of the cranial walls, 
and also from causes directly increasing the blood-pressure in 
the brain, i. e., whooping-cough, bronchitis, emphysema and 
convulsions ; indeed, a history of convulsions can be obtained 
in most cases. Syphilis and rickets, by inducing malnutri- 
tion of the osseous system and anaemia, may act as predispos- 
ing causes. Some cases are distinctly inflammatory, the pro- 
cess attacking the ependyma of the ventricles and of the 
choroid plexus. In these cases the fluid is turbid, containing 
blood and pus cells. The cause of the inflammation is diffi- 
cult to determine. A syphilitic history can be obtained in 
some instances, and in others a hereditary predisposition 
seems to exist. 

The amount of fluid is sometimes enormous ; it may amount 
to several pints. 

The brain is greatly distended, the convolutions become 
obliterated, and the cortex may become a mere shell or the 
brain appear as a large cyst. The cranial bones are thin and 
the sutures widely separated. In rare instances premature 
ossification of the cranium occurs with hydrocephalus. Spina 
bifida and other congenital defects may be found associated. 

The symptoms of a typical case are mainly objective. The 
head is rounded, its size much out of proportion to the rest of 
the body and in its relation to the development of the face, 
and the fontanelles and sutures are wide open and tense. In 
external hydrocephalus the enlargement is usually not so pro- 
nounced, and when the skull is still soft fluctuation can be 
elicited over the head. 

It is necessary to remember the normal circumference of 
the head at different periods of infancy in order to determine 
whether the head be abnormally large. At birth the circum- 



470 DISEASES OF CHILDREN. 

ference should be about fourteen inches, and at the end of the 
first year nineteen inches. Beside this, the relationship of the 
circumference of the head to the chest is important to bear in 
mind, the circumference of the head at birth exceeding that 
of the chest by half an inch ; later, during the entire period of 
infancy, the two measurements are practically equal. From 
these data it is easy to determine an abnormally developing 
head. Every cranial enlargement does not, however, indicate 
hydrocephalus, the most important condition to be differenti- 
ated being rickets. 

Hydrocephalus may occur without enlargement of the head. 
In such cases there is either premature ossification of the 
skull or a late onset of the disease. They are generally 
idiots, and die early (Hoet). It is impossible to recognize 
this condition during life. 

The rate at which the head enlarges varies greatly ; the 
earlier and more rapidly the enlargement develops the more 
serious the prognosis. Cerebral symptoms are slight, often 
entirely wanting. The development of the child is, however, 
much retarded, and the majority of cases die early of maras- 
mus. Those surviving this period die in early childhood, as 
a rule, from some intercurrent disease. The mind becomes 
affected and many are idiots. They are irritable and often 
show evidence of violent temper. In others, again, the intel- 
ligence is but slightly interfered with and the}- live beyond 
the proscribed period, being, however, entirely helpless owing 
to their enormously sized heads. 

The differential diagnosis between hydrocephalus and 
rickets should present no difficulties, excepting when the two 
conditions co-exist. This is quite rare, but even then the 
hydrocephalus soon takes the upper hand, the rachitic con- 
dition falling in the background. 

As has been said above, the hydrocephalic head is enlarged 
out of all proportion to the rest of the body, and presents a 
regular rounded outline. The root of the nose is prominent 
and the eyes are deflected downward, so that the lower lid 



DISEASES OF THE NERVOUS SYSTEM. 



471 



crosses the iris higher than normal. The face is small in 
comparison with the head. The fontanelles are bulging and 
pulsate, and the sutures widely separated, while the cranial 
bones feel thin. Fig. 48 represents a case of moderate 
severity in which the differentiation from the rachitic head 
is clearly shown. In rickets, on the other hand, the head is 
square and the centres of ossification in the frontal and pari- 
etal bones are hypertrophied. The skull is hard excepting 
in the occipital region, where craniotabes may be present. 




FIG 48. — A CAS1': OF HYDROCEPHALUS DEVELOPING SEVERAL MONTHS 
AFTER BIRTH, SHOWING THE EARLIER PERIOD OF THE DISEASE. 



Enlarged epiphyses and deformities in the extremities are as- 
sociated. 

The treatment is unsatisfactory. So far, surgical interfer- 
ence has availed but little, and seems only applicable to the 
external form. Spontaneous cures by discharge of the fluid 
through the nose and scalp are on record. 

Strapping the head may be tried as an adjuvant, but it 
must be done with caution. Bartlett (Goodno's Practice) 
mentions the cures effected by the application of solar heat, 



472 DISEASES OF CHILDREN. 

which is a measure that should at least be tried. "The 
method consists in exposing the child's occiput to the direct 
rays of the sun for twenty minutes each day, gradually in- 
creasing the duration of the seance until the limit of thirty or 
forty minutes is reached. It is believed that the local sweat- 
ing acts to remove a portion of the effusion, while the thermic 
heat aids nutrition." 

When a distinct syphilitic history can be obtained the case 
should be treated as one of congenital syphilis. 

Grauvogl has recommended that in cases where a family 
tendency to hydrocephalus exists the mother should receive 
Sulphur and Calcarea carb. during every pregnancy, admin- 
istered at suitable intervals. 

The following remedies are to be studied : 

Baryta carb. — Deficient development, both physically and 
mentally. 

Calcarea carb. — "Fat babies with large heads; wide open 
fontanelles, which are often covered with dirty, scurfy skin 
fair complexion; precocious; head sweats profusely, espe 
cially on occiput; abdomen large and sensitive to pressure 
bowels inclined to be loose, feet damp and cold, dentition dif 
ficult" (C. G. R.). 

Calcarea phos. — "Flabby, shrunken, emaciated children 
skull thin and soft, with fontanelles wide open; cannot stand 
and do not learn to walk, want to nurse all the time ; retarded 
dentition; emaciation with loose, green stools" (C. G. R.). 

Lycopodzwn. — "Children sleep apparently soundly, but 
scream out suddenly in sleep, stare about and cannot be paci- 
fied" (C. G. R.). 

Kali hydriodicum should be tried when there is a syphilitic 
history. 

Silicea. — Profuse sweating about head and neck ; pale, del- 
icate children with tuberculous tendency; rickets, malnutri- 
tion of osseous system. 

Sulphur. — Children with unhealthy skin, cutaneous erup- 
tions, symptoms appearing after suppression of eruption, vora- 
cious appetite ; old, withered look. 



DISEASES OF THE NERVOUS SYSTEM. 4-73 

Other remedies that have been recommended are Thuja, 
Psorimtm and Tuberculinum, and for the removal of the effu- 
sion, Apis, Apocynum and Helleborus are spoken of, but, as 
Bartlett suggests, their administration will be attended with 
disappointment. More reliance is to be put in the constitu- 
tional treatment. 

CONVULSIVE AFFECTIONS. 

Eclampsia, or Infantile Convulsions. — General convulsions 
occur in infancy from a variety of causes, and are among the 
more frequent of the nervous disorders incident to this period 
of life. In many respects these seizures bear great resem- 
blance to idiopathic epilepsy, but the latter condition is not 
seen in early childhood, nor does it run the same clinical 
course nor depend upon the same etiological factors as infan- 
tile convulsions. Eclampsia may be looked upon as an ex- 
plosive discharge of nerve force in the motor areas, brought 
about by a condition capable of suspending momentarily the 
normal controlling influence of the higher inhibitory centres. 
Such a factor may be found in reflex irritation, i. e., sensory 
impulses originating in various parts of the body by being 
carried to the cerebrum along the afferent nerve fibres, tran- 
siently disturbing the controlling element in these centres. 
The modern view, however, rather favors the belief that the 
majority of cases are toxic in origin. 

Although infancy of itself predisposes to convulsions by 
reason of the rapid growth of the brain and the instability of 
the nerve centres, still a healthy and properly cared for child 
rarely develops them. There is usually some constitutional 
disturbance, or a general disease affecting directly the nutri- 
tion of the nervous system. For this reason rickets plays 
such a prominent role as a predisposing cause. 

As reflex causes may be mentioned phimosis ; dentition ; 

the presence of undigested food particles, foreign bodies or 

worms in the intestinal tract and retention of urine. It is 

doubtful whether teething, per se, ever produces convulsions, 

3 1 



474 DISEASES OF CHILDREN. 

and in considering the other causes it is often difficult to de- 
cide whether they act reflexly or whether they do not actu- 
ally set up an auto-intoxication. 

To the toxic cases belong those convulsions ushering in an 
acute infectious disease, or occur as a result of indigestion ; 
uraemia ; asphyxia ; jaundice ; diabetes ; anaemia ; drugs. 
Lastly are to be mentioned the convulsions resulting from 
direct cortical irritation and occurring in meningitis ; cerebral 
haemorrhage, abscess or thrombosis ; hydrocephalus ; brain 
tumor, injury at birth. 

The anatomical lesions found in children dying in con- 
vulsions are by no means constant or characteristic. The 
changes occurring in the brain are probably anaemic, fol- 
lowed by venous hyperaemia. When intense congestion, 
serous effusion and punctate haemorrhages are found after 
death they are to be looked upon as a result of the convul- 
sion and not as a cause of the same, death having resulted 
from asphyxia. The initial stage of a meningitis may also 
be found ; or, if the convulsion depends upon organic brain 
disease, such a condition becomes evident. 

Symptomatology. — Infantile convulsions are most fre- 
quently general, although a localized or partial convulsion 
may result as well from reflex irritation as from organic dis- 
ease. In such cases the subsequent course of the disease 
alone will clear up the mystery, if unmistakable evidence of 
organic disease or reflex irritation cannot be elicited at the 
first examination of the case. Even a more extensive con- 
vulsion shows a tendency to begin in one extremity a few 
seconds before it passes to the remaining half of the body or 
becomes general; but the true local convulsion, or Jacksonian 
epilepsy, repeatedly commences in one extremity, and if it does 
not remain local, at least continues so for an appreciable time 
(Herter). This form of convulsion is indicative of organic dis- 
ease, the nervous discharge commencing at the seat of irrita- 
tion. With it there is no loss of consciousness. Prodromal 
symptoms are therefore usually present, indicating the com- 



DISEASES OF THE NERVOUS SYSTEM. 4:75 

mencement of a general convulsion. They may be so slight 
as to be entirely overlooked, or they may manifest themselves 
as extreme restlessness, twitching of the mouth, eyelids, ex- 
tremities, and rolling of the eyes. 

The convulsion proper is very similar to an epileptic fit. 
The child becomes suddenly rigid, the neck being thrown 
back, the hands clenched, with thumbs buried in the palms, 
and the extremities stiffen out. This stage is only of short 
duration, not as long as in a true epileptic attack, while the 
succeeding stage, consisting of intermittent spasmodic con- 
tractions of the extremities, is comparatively longer. During 
this stage the entire body is seen to take part in alternate 
rhythmical contraction and relaxation. The child is per- 
fectly unconscious, and may involuntarily pass both urine 
and faeces. In the course of a few minutes to half an hour, 
according to the gravity of the case, the spasms gradually 
subside, leaving the child in a soporous condition. It is not 
uncommon for several convulsions to occur in succession, 
as repeated convulsive seizures create a susceptibility from 
which the nervous system recalls itself with difficult}-. 

The prognosis depends upon the nature of the exciting 
cause and the course pursued by the seizure. When convul- 
sions recur in rapid succession, or when associated with 
laryngismus stridulus, the prognosis becomes grave. Like- 
wise in convulsions occurring with uraemia or with menin- 
gitis, extensive haemorrhage, or other serious intra-cranial 
lesion, the prognosis is grave. Should the convulsive habit 
become firmly established the child is quite likely to develop 
idiopathic epilepsy. 

Diagnosis. — The differentiation of symptomatic from idio- 
pathic eclampsia rests upon a proper examination of the pa- 
tient for evidence of disease elsewhere. Thus, with convul- 
sions ushering in the infectious fevers, there are always the 
symptoms belonging to the stage of invasion of the particular 
fever in question. In uraemic convulsions the urine tells the 
tale. Those due to reflex irritation give evidence of such a 



4-76 DISEASES OF CHILDREN. 

source of irritation, and a purely rachitic case becomes self- 
evident by inspecting the child closely. Intra-cranial dis- 
turbances are recognized by characteristic symptoms present 
before the convulsions have made their appearance. 

Convulsions occurring shortly after birth are usually due 
to meningeal haemorrhage. Unilateral spasms may occur 
from cortical haemorrhage, as a result of whooping-cough, 
trauma or idiopathic origin. 

Epilepsy is to be suspected when repeated convulsive seiz- 
ures occur in children over three years of age, notwithstand- 
ing the absence of any source of reflex irritation or other 
cause to account for the attacks. Other symptoms, such as 
aura and the stigmata of degeneration, are usually ascertain- 
able. 

Treatment. — All exciting causes must be removed at once 
when this is possible, and the predisposing cause is to be 
overcome by attending to the child's general condition. Con- 
stitutional remedies and a properly-selected diet, together 
with plenty of fresh air and sunshine, are indispensable here. 
(See Rickets.) 

As gastro-intestinal irritation plays such an important role 
in the precipitation of convulsive seizures, the stomach and 
bowels should at once be emptied when the attack is sus- 
pected to arise from this source. 

During the seizure every article of clothing should be 
loosened. If the convulsion lasts for any considerable length 
of time a warm bath, together with cold applications to the 
head, is indicated. In long-continued or recurring convul- 
sions a hot pack or a weak mustard pack is more practicable. 

The most frequently indicated remedies are Belladonna, 
Cuprum, Cicuta, Ignatia and Magnesia phos., basing our pre- 
scription purely upon the occurrence of convulsions. But 
when the convulsion is purely symptomatic, the results of 
treatment will be more satisfactory if we direct our attention 
to the exciting cause instead of looking upon the convulsion 
as an independent disease. 



DISEASES OF THE NERVOUS SYSTEM. 477 

Aeon. — High fever ; high arterial tension ; great restless- 
ness. Febrile cases. 

Bell. — Convulsions, with flushed face ; dilated pupils ; 
cerebral congestion ; throbbing carotids ; pyrexia. Indicated 
in those cases ushering in the infectious fevers, in some reflex 
convulsions, and in convulsions occurring in the early stages 
of meningitis. 

Cuprum. — Convulsions beginning in the fingers and toes, 
becoming general, with marked cyanosis. Spasm of the 
glottis is associated with these cases. Convulsions occurring 
during the eruptive fever when the rash disappears ; whoop- 
ing-cough ; meningitis {Cupr. acet.). 

Cuprum ars. is most valuable in ursemic convulsions. 

Cina. — Reflex convulsions from irritation of the intestinal 
tract, whether due to worms or not. The spasmodic move- 
ments are often confined to the eyes and face, continued with 
irregular jerkings of the extremities. In this respect it is 
similar to Chamomilla, which presents many of the premoni- 
tory symptoms of eclampsia, the child being feverish, irri- 
table, and suffering with intestinal colic or painful teething. 
In such cases Chamomilla will frequently ward off a con- 
vulsion. 

Cicuta. — The convulsion comes on suddenly without pre- 
monitory signs. The stage of tonic spasm is well marked, 
and the child may remain rigid for a long time, only a few 
jerks of the extremities being noticed during the attack. It 
usually points to cerebral effusion. 

Ignatia. — Convulsions in nervous subjects brought on by 
fright or peripheral irritation. The vascular excitement of 
Bellado?ina is not present in these cases, and the face is in- 
clined to be pale instead of hot and flushed, as in the latter 
remedy. 

Magnesia phos. — Idiopathic convulsions; defective nutri- 
tion of the nervous system. (See Epilepsy.) 

Opium. — Convulsions in cerebral haemorrhage. There is 
trembling of the whole body ; purplish color of face ; stertor- 
ous breathing and sopor ; post-epileptic stupor. 






478 DISEASES OF CHILDREN. 

Veratrum viride. — Great vascular excitement with high 
arterial tension ; opisthotonos ; eyes injected and staring ; 
intense cerebral congestion. 

Beside these remedies compare also Apis, Calc. curb., Gels., 
Helleb., Hyos., Stram., Ipecac, Sulph. and Zincum, and con- 
sult the article upon Meningitis and Laryngismus Stridulus. 

EPILEPSY. 

Idiopathic epilepsy is a condition in which recurring 
attacks of unconsciousness with convulsions (gra?tdmal) 
or without convulsions (petit mal) are firmly established, 
ultimately leading to an impairment of the subject's 
mentality. 

Etiology. — Heredity plays a most important role in the 
etiology of epilepsy, the tendency springing not only from 
the presence of epilepsy, but also of other nervous diseases, 
such as hysteria, neurasthenia and insanity in the family his- 
tory. Parental syphilis and alcoholism are looked upon as 
causes. In some of my cases pronounced rachitic changes 
were present and the convulsions dated back to infancy. The 
majority of epileptics show in more or less degree the evi- 
dences of degeneracy, both physical and mental ; indeed 
many are vicious and criminally inclined, while others show a 
low moral standard or deficient intelligence. Startling excep- 
tions in the form of geniuses, of course, are observed. As to 
age, the period of puberty furnishes the majority of cases. It 
only rarely develops before the third year. Sachs ( The Nervous 
Diseases of Children) is of the opinion that hereditary (idio- 
pathic) epilepsy is not as common as is generally supposed, 
many cases being accepted as such because a former cerebral 
lesion or a traumatism to the head has been overlooked owing 
to the disappearance of the paralysis and other symptoms due 
to such a lesion, from which, however, the epilepsy dates. 
To this category belong those cases of epilepsy associated 
with infantile cerebral palsies and defective general develop- 
ment of the brain. 



DISEASES OF THE NERVOUS SYSTEM. 479 

The exciting cause of the seizure is most often found in 
disturbances of the digestive tract. Acute indigestion, either 
through reflex irritation or auto-intoxication, will frequently 
precipitate an attack. Reflex irritation from phimosis, eye- 
strain, worms, etc., exerts a similar influence. Emotional 
excitement, excessive physical exertion, and poorly ventilated 
or crowded apartments are most disadvantageous to the 
epileptic. In several of my cases the first seizure developed 
after a slight traumatism, the psychic effect no doubt being 
more to blame than the accident itself. 

A constant pathological lesion is not to be found. Judging 
from our knowledge of the physiology of the brain and the 
symptoms produced by irritation and organic disease of the 
cortex in the Rolandic area, it is reasonable to suppose that 
the pathologic condition must be located here. Indeed, a 
number of observers, notably Van Giesen and Bleuler, have 
demonstrated changes in the cortical cells and in the neu- 
roglia. Lesions in the basal ganglia have also been described. 
These are probably in the nature of secondary changes. 
Onuf {Jour. Amer. Med. Asso., April, 1905) reports the find- 
ings in sixteen carefully conducted autopsies. He discov- 
ered in ten cases marked thickening of the pia over the 
fronto-panetal lobe. There was also atrophy in the thalmic 
region. Whether these thalmic changes are directly con- 
nected with the seizure, or only part of a general pathologic 
condition of the brain, it is not possible to say. 

Symptomatology. — An attack of petit mal is characterized 
by a momentary loss of consciousness, unaccompanied by 
convulsions or other nervous phenomena. In children it is 
often looked upon as mere absent-mindedness or a fainting 
spell ; in older subjects it is more likely to be confounded 
with vertigo, with which, it is unnecessary to say, it has noth- 
ing in common. After this condition has once been fully 
established, a change in the child's mentality becomes mani- 
fest; it may go over into the convulsive form or exist in con- 
junction with the same. 



480 DISEASES OF CHILDREN. 

Besides petit mal there are numerous other forms of incom- 
plete seizure, all however attended by momentary loss of 
consciousness. There may be merely twitching of certain 
muscles, notably in the arm and face ; a sudden impulse to 
run forward or perform other automatic movements, uncon- 
sciously. Sometimes coma exists without convulsions, or the 
child may have aurae for a long time before the convul- 
sions make their appearance. There are also certain psychic 
equivalents of the epileptic seizure, in the form of maniacal 
and other insane acts. Following the fit, the patient may for 
several days perform acts for which he is irresponsible. 

An attack of grand mal is very similar to an attack of in- 
fantile convulsions ; but other conditions are added thereto, 
and the various stages are more sharply defined and charac- 
teristic. The following stages are to be observed : 

(i ) The aura or prodromal symptoms. This usually con- 
sists of a sensory disturbance, which may be variously de- 
scribed as a tingling ; feeling of numbness ; crawling ; sen- 
sation of a gust of wind directed, upon the affected part ; 
hallucinations of sight, smell and hearing. There may also 
be motor disturbances, and the character of the aura will in 
many instances point to involvement of a special area of the 
cerebral cortex. 

(2) The initial cry. This marks the commencement of the 
stage of tonic spasm. The patient utters a loud cry, as a re- 
sult of the spasmodic contraction of the respiratory muscles 
forcing the air through the partially closed glottis, whereupon 
he falls to the ground as if shot. With this stage, uncon- 
sciousness also sets in. 

(3) The tonic spasm. During this stage the body is per- 
fectly rigid, the legs extended, the arms flexed and the hands 
clenched, the thumbs being pressed into the palms of the 
hands by the fingers. The head may be retracted, causing 
opisthotonos (young children), or it may be drawn to one side, 
the eyes being fixed and pointing in the same direction. The 
pupils are immovably dilated. The face, at first pale, now 






DISEASES OF THE NERVOUS SYSTEM. 481 

becomes reddened, and even cyanotic, if the stage is pro- 
longed. The jaws are set, and the tongne is frequently 
caught between the teeth. The stage of tonic spasm lasts for 
a period of about a minute, at the end of which time it grad- 
ually subsides, being followed by — 

(4) The stage of clonic spasjn. This consists of alternate 
relaxation and contraction of the muscles of the extremities 
and thorax, persisting for several minutes (seldom over five 
minutes). Through these movements the body is thrown 
into violent action, and frothy saliva is ejected from the 
mouth, the tongue quite frequently being caught between the 
teeth and badly bitten. Urine and faeces are frequently 
passed involuntarily. The movements gradually subside and 
the patient goes over into — 

(5) The stage of stupor. Post-epileptic stupor is a profound 
sleep from which the patient may be temporarily aroused, but 
soon relapses into unconsciousness. This may last for several 
hours. The pupils are dilated. 

Prognosis. — Cases of epilepsy coming under treatment 
early, providing there is no organic lesion or mental deficiency 
associated with the same, should not be despaired of as ab- 
solutely incurable. Traumatic epilepsy has been cured by early 
surgical interference. Hereditary cases offer a bad prognosis, 
as they usually present degenerative tendencies. u More 
favorable are those cases which come on during the period of 
dentition, or are caused by disturbances in the nutritive func- 
tions, such as chlorosis or anaemia ; in fact, in all cases where 
it is possible to remove the cause" (C. G. R.). From this it 
will be seen why the best results in treatment are obtained 
by attending strictly to the patient's diet and hygienic sur- 
roundings, and by prescribing upon constitutional and gen- 
eral indications rather than upon the convulsive symptoms. 

Diagnosis. — Eclampsia: Prior to the age of three years, 
longer duration, reflex irritation or organic disease ascertain- 
able. The convulsions are liable to recur after a short time, 
while in epilepsy a long interval b usually present (Bart- 
LETT). 



482 DISEASES OF CHILDREN. 

Hy steroid convulsions are usually precipitated by emotional 
excitement ; rigidity is marked, followed by irregular move- 
ments of the extremities ; the duration is much longer than 
an epileptic seizure, and there is no biting of the tongue or 
involuntary micturition and defecation (Gowers). 

Other conditions to be thought of are urcemic and other 
toxic convulsions, and, in the case of petit mal, syncope and 
vertigo must be excluded. 

Frequently we are called upon to make a diagnosis in a 
case where the occurrence of convulsions is not known. 
Thus, we may find a patient in post-epileptic coma, or have 
to deal with a case of nocturnal epilepsy where the convul- 
sions have taken place unobserved. Post-epileptic coma is 
distinguished from uraemia by the pupils and the absence of 
albuminuria and casts in sufficient amount to indicate ne- 
phritis. The tongue should be carefully examined for scars. 
Strumpell lays stress upon a careful inspection of the con- 
junctivae and face for punctate haemorrhages. When these 
are seen in a patient who awakens in the morning dull and 
confused we have strong presumptive evidence of nocturnal 
epilepsy. When this is associated with enuresis the pre- 
sumption is still stronger. Besides, in forming an estimate 
of the true nature of any condition associated with disturbed 
or temporary loss of consciousness the family history and the 
child's physical and mental development play an important 
role. 

Treatment. — All sources of reflex irritation, such as phi- 
mosis, cicatrices, errors of refraction and nasal defects must 
be corrected at once. The diet is of great importance. The 
patient should be kept mainly on a vegetable diet, allowing 
milk regularly, and poultry and fish only occasionally ; fur- 
thermore, the stomach must never be overloaded, and, beside 
prohibiting meat, all indigestible articles of food, such as 
pastry, rich desserts, etc., must be strictly avoided (Bart- 
lett). 

In cases of malnutrition, meat may occasionally be allowed, 



DISEASES OF THE NERVOUS SYSTEM. 483 

but a liberal meat diet is always bad for children. Cases in 
which convulsions had ceased under an exclusive vegetable 
and milk diet invariably relapse when meat was allowed, no 
change in the medicinal treatment having been made 
(Thompson, Practical Dietetics). Codliver oil is indicated 
in the rachitic and strumous. 

It is a noteworthy fact that an excess of Indican is found in 
the urine of many epileptics just about the time of the seizure 
(HERTER), being formed in the intestines from the excessive 
putrefaction of proteids. This points to the necessity of pre- 
venting intestinal putrefaction, which may be at least par- 
tially accomplished by careful regulation of the diet. Indi- 
canuria is produced not only by the ingestion of albuminous 
food, but also as a result of muscular atony of the stomach 
and hypochlorhydria. As the lactic acid bacillus is antago- 
nistic to the colon bacillus, and should in fact predominate 
over the latter in the small intestines in childhood, it is 
readily seen why a milk diet and the prohibiting of meat is so 
beneficial in epilepsy. 

Excessive physical exertion must be avoided, while judi- 
cious out-of-door exercise proves of the greatest benefit.. 

During an attack the patient should be protected from 
doing himself injury. A towel or other available article 
may be inserted between the teeth to prevent biting the 
tongue, and the clothing should immediately be loosened. 
The inhalation of Amyl nitrite sometimes shortens the attack. 

As before stated, the best results are obtained from remedies 
selected upon general indications, taking into consideration 
the patient's mental, temperamental and diathetic peculiar- 
ities ; also, any disturbances in the alimentary, respiratory, 
genito-urinary tract, etc. For this reason such remedies 
as Cicnta, Hydrocyanic acid, CEnanthe crocata and Solatium 
are rarely of positive value. On the other hand, Argentutn 
nitr., Calc. carb. and phos., Lycop., Nux vom., Pulsatilla, Silica 
and Sulphur are of the greatest service. There are, however, 
a few anti-spasmodic remedies which are among the most use- 



484 DISEASES OF CHILDREN. 

ful in epilepsy, but their action, as at once seen from a study 
of their pathogenesy, is a deep, selective one, not simply in- 
ducing transient functional disturbances. I refer mainly to 
Cuprum and Magnesia phos. Magnesia phos. has given me 
good results in cases of idiopathic epilepsy in so far that it 
greatly reduced the frequency of the paroxysms and lessened 
their severity; but as they were mostly dispensary and 
hospital cases., they were not observed for a sufficient length 
of time to judge of any permanent results. The prompt 
action obtained from this remedy in a case of tetany of long 
standing certainly points to its efficacy as an anti-spasmodic 
of great value. 

Where disorders of the digestive tract and lithsemic symp- 
toms are prominent conditions Nux vom., Lycopodium, Cina 
and Sepia stand out prominently. 

In petit mal I have obtained positive benefit from Cannabis 
Indica in small doses. The seizures occurred less frequently 
and the child's general condition was improved. Another 
remedy from which I have obtained results and practically use 
as a routine in beginning the treatment of any case is San- 
tonin. Whether or not worms are present, Santonin certainly 
is helpful in all cases of intestinal indigestion, and relieves 
many of the symptoms resulting therefrom. 

The following resume is given in order to call attention to 
the guiding indications for the important remedies: 

Arnica. — Recent traumatic cases. 

Arg. nitr. — Old-looking face, pupils dilated before parox- 
ysm for a day or two, flatulent dyspepsia with cardiac pal- 
pitation, apprehensiveness and depression of spirits, attacks 
of hemicrania, periodic trembling of body and paralytic weak- 
ness, epilepsy from fright, masturbation, menstrual difficulties. 

Arsen. — Anaemic, weakly subjects. Burning in the spine, 
burning in the stomach and bowels after eating, diarrhoea 
with smarting about anus. Petit mal. 

Bell. — Violent convulsions, with marked cerebral conges- 
tions; mania. Prodromal symptoms consist of flushing of 






DISEASES OF THE NERVOUS SYSTEM. 485 

the face, throbbing of the carotids ; wild, staring expression ; 
feeling of suffocation. During the interval, throbbing head- 
ache, vertigo, flushing of the face with burning heat, easily 
frightened, night terrors, enuresis. Stramonium is similar in 
many respects. Symptoms brought on by fright, with great 
nervous excitement; spasmodic constriction of the throat, 
gyratory movements of extremities and threatened convul- 
sions. Stramonium is frequently of service when Belladonna 
has failed to give relief, or its chances for doing good have 
slipped by, as it is of no service in old cases. The cases in 
which Hyoscyamus has proven so beneficial are undoutedly 
hysterical in nature, as Jahr intimates. Such causes as "dis- 
appointed love, jealousy and grief," mentioned under the eti- 
ology of Hyoscyamus, point to the hysterical element in these 
attacks, as also such symptoms as "attempts at swallowing 
fluids renew the attacks," and "inclined to talk a great deal 
after the attacks; slight wandering of the mind." 

Bufo. — Bojanus {Die Horn. Therapeutik in ihrer Anwen- 
dung auf die Operat. Chirurg., 1880) reported a series of 
twenty-two cured cases of epilepsy, among which four were 
cured by the use of Bufo alone, three with Bufo followed by 
Salamander, and two with Bufo in conjunction with Lachesis 
and Ignatia. He gives no special indications for this rem- 
edy. "After fright or onanism; attacks at night, followed 
by some hours of coma; loss of consciousness and falling 
down ; tonic and clonic spasms ; turgescence and distortion 
of face ; bites tongue ; involuntary emission of urine ; the 
lower extremities are more in motion than the upper ones." 
— (C. G. R.) 

Calc. carb. — Scrofulous diathesis and leucophlegmatic tem- 
perament. Anaemia; catarrhal and cutaneous affections; 
prominent belly ; cold hands and cold, sweaty feet ; sweating 
about the head. "Frequently indicated after Sulphur," or in 
conjunction with Belladonna. 

Cannabis Indica. — Clinically useful in petit mal. Allen 
{Handbook of Materia Medico) gives the following symptoms 



486 DISEASES OF CHILDREN. 

as marked: Absent-minded, forgetful of what he intended to 
write or speak so that he cannot finish a sentence ; forgetful 
of his last words and ideas. Unconsciousness every few 
minutes. Misapprehensions concerning time and space. 

Causticum. — Where the mind is affected and paralytic affec- 
tions are associated with the epilepsy. Degenerative changes 
in the nervous system. Paralytic weakness after the seizure 
is marked. Cases caused by fright (also Ignatia, Hyos. and 
Stram.) ; nocturnal epilepsy (also Cupr., Calc. c, Opium and 
Lycop.), and those following suppression of eruptions (Ars., 
Cupr., Calc. c. and Sulph.). 

Cicuta. — Violent epileptiform spasms, accompanied by 
puffed, bluish face ; fixed, staring eyes ; terminating in trem- 
bling and long-continued sopor. Intestinal irritation, with 
venous congestion of abdomen. 

Cimicifuga rac. — Epilepsy associated with disturbances in 
the female generative organs. 

Cina and Santonin are useful at some time or other in most 
cases. Ridding the intestinal tract of parasites is one of the 
first things to be thought of in epilepsy in children. Besides 
the symptoms directly referable to worms there are a number 
of others calling for Cina, particularly those referable to the 
disposition, the appetite and general nutrition. 

Cuprum. — Clear, idiopathic cases without organic lesions. 
The attacks may have been precipitated by fright, mental 
excitement, or suppressed exanthemata. The attack is typi- 
cal, and cyanosis is usually marked. 

Gels. — Dull occipital headache before attack ; languor ; 
drooping of eyelids ; easily frightened into diarrhoea ; pro- 
longed spasm of the glottis during attack. 

Glonoin. — "Great congestion of head and right heart; 
during spasm he spreads his fingers and toes asunder." — 
(C G. R.) 

Hypericin?/. — After injury to the spine or peripheral 
nerves. 

Ignatia. — This remedy is especially suited to ordinary 



DISEASES OF THE NERVOUS SYSTEM. 487 

cases of epilepsy in children. They are exceedingly nervous 
and easily frightened, irritable and peevish, and difficult to 
control. Jahr considered it the most valuable remedy with 
which to begin a case. 

Indigo. — Depression of spirits. Excitable, furious and 
easily angered before the attack. Melancholy, timid or 
gloomy after the attack (L. M. Kenyon). 

Lachesis. — Auto-intoxication marked. The stools are ex- 
ceedingly offensive. Phlegmatic constitution with disposi- 
tion to indolence and melancholy. 

Nux vom. — Indigestion with attacks of canine hunger ; 
constipation, tongue coated posteriorly, bad taste, headache 
on rising in morning, with irritability (Lycop., great irrita- 
bility after sleep) and anorexia, especially mornings. Nux 
vom. and Lycop. are very important general remedies for the 
epileptic. 

Ophim. — Prolonged post-epileptic stupor. Nocturnal cases, 
with mental derangements. 

Silica. — Lack of animal heat ; strumous and rachitic dia- 
thesis ; neurasthenia ; pale, transparent skin ; profuse sweat 
after the seizure. "Epilepsy, the aura begins in the solar 
plexus. Chronic effects of fright and nervous shock. Great 
irritability; constant restlessness" (T. F. Allen). 

Sulphur. — Scrofulous or psoric diathesis. It is unneces- 
sary to describe the characteristic Sulphur child here. Sul- 
phur is also important as an intercurrent, or in cases not re- 
sponding to the usual list of remedies. 

The Bromides. — When after careful study and conscien- 
tious efforts to control a case of epilepsy by means of a rem- 
edy chosen purely symptomatically in conjunction with faith- 
fully carried out hygienic measures, the seizures still persist 
and recur with alarming frequency, whereby the patient's 
general condition and mental state are profoundly affected, then 
it becomes imperative to control the convulsions by physio- 
logical means. Not that the use of the Bromides is entirely 
unattended by unfavorable results, but these are compara- 



488 DISEASES OF CHILDREN. 

tively mild and easily removed when compared to the under- 
mining influence of oft-repeated convulsions upon the nerv- 
ous system. Having a limited experience in the use of these 
remedies, I cannot do better than quote from the leading old- 
school authorities in neurology : 

" It is certain that very few cases have been permanently 
cured by the administration of Bromides ; but unquestionably 
they serve an admirable purpose in checking the number of 
attacks and in diminishing their severity. To accomplish 
this end the Bromide salts should be administered according 
to a definite plan. It has been my practice to give prefer- 
ence to the Bromide of sodium, which I employ, according to 
the age of the patient, in ten or fifteen-grain doses, three times 
a day. If given in a wineglassful of (alkaline) water after 
meals the gastric functions will not be seriously impaired. 
... In the case of nocturnal attacks the medicine should 
be given before going to bed [the entire daily dose] , and at 
no other time. — (Sachs. Nervous Diseases of Children?) 
The method recommended by Seguin {New York Med. Jour., 
March, 1890) has many followers. It consists in the admin- 
istration of the larger part of the full daily dose shortly be- 
fore the time when a seizure is to be expected. During the 
interval a much smaller dose is employed, and the bromide is 
always given highly. diluted. 

According to Bayley, the Bromide of strontium is less irri- 
tating, produces less acne and has seemed to him more satis- 
factory in results than those obtained from the Sodium or 
Potassium salt. He gives from ten to eighty drops of a satu- 
rated solution (each drop representing about y 2 grain of the 
salt) after meals, well diluted. If favorable effect is noted, 
sufficient dosage is maintained to stave off the paroxysms. 
It has been claimed recently that the action of the bromides 
is augmented and that therefore the dose can be reduced if 
we entirely interdict the use of table salt at the time the 
patient is taking bromides. 

As soon as the paroxysms are controlled the dose is de- 



DISEASES OF THE NERVOUS SYSTEM. 489 

creased to a minimum, but the remedy should not be with- 
drawn immediately. 

TETANY. 

Tetany is a neurosis characterized by tonic spasms, occur 
ring principally in the extremities. The spasm may remain 
confined to these parts or it may extend to other groups of 
muscles, thus involving the neck, trunk, thorax and abdo- 
men. Strabismus and trismus may likewise be present, but 
they occur secondarily to the spasm of the extremities, con- 
trary to the occurrence of trismus in lockjaw, where it is the 
primary manifestation. The spasm may be intermittent in 
character or persistent. In the majority of my cases it was 
persistent, recovery taking place in from one to two weeks. 

Etiology. — The close association of tetany with laryngismus 
stridulus and rickets points to a general disturbance in the 
nutrition of the nervous system as the cause underlying these 
phenomena. Escherich has shown that in cases of laryngo- 
spasm, even in the absence of fully developed tetany, he could 
bring out some of its latent symptoms. The tetanic spasms 
can be explained upon the theory of an increased excitability 
of the gray matter of the brain, medulla and cord, resulting 
from the above-mentioned cause. It is not at all unlikely, 
however, that toxic irritation of the motor cells in the gray 
matter of the brain and cord produces the contractures, the 
toxin emanating from the intestinal tract. My own experi- 
ence leads me to accept this explanation in view of the fact 
that I have seen tetany in infants without signs of rickets and 
in which the symptoms promptly disappeared after a regula- 
tion of the diet. An infectious origin is believed in by some. 
Koplik has seen most of his dispensary cases appearing in 
groups in the early spring months. The disease is not com- 
mon in this country, and the majority of cases have been ob- 
served between the ages of one and five, males being more 
frequently affected than females. As exciting causes, intes- 
tinal irritation, persistent diarrhoea, teething, phimosis, ex- 
32 



490 DISEASES OF CHILDREN. 

posure to cold, and exhausting acute illnesses, such as typhoid 
fever and pneumonia, have been mentioned. Extirpation of 
the thyroid gland has frequently been followed by tetany in 
adults. Enlarged thymus is mentioned by Escherich. 

Symptomatology. — Children who are old enough to express 
their feelings may complain of a tingling or numbness in the 
extremities preceding the attack. The spasm comes on sud- 
denly, involving first the fingers and wrists, after which the 
toes and ankle-joints become fixed in a characteristic attitude. 
This is described as the "carpo-pedal spasm." The fingers 
are straightened out and flexed at the metacarpophalangeal 
joints, while the wrists are likewise flexed and the thumb 
drawn in under the fingers. The feet are in a position of 
talipes equinus, with the toes extended and flexed at the 
metatarso-phalangeal joints. As stated above, the spasm may 
extend to other groups of muscles, causing opisthotonos, tris- 
mus, strabismus or dyspnoea, according to the locality af- 
fected. A cramp-like pain may be complained of in the 
muscles, and any attempt to extend the extremities or to 
place the child on its feet causes a painful strain upon them. 
After a variable period the spasm relaxes and an interval of 
several hours or days may occur. In particularly aggravated 
cases, however, the child does not appear entirely free from 
the spasmodic condition, evidence of slight rigidity and weak- 
ness of the affected muscles being present. There is another 
group of cases in which the hands and arms take the position 
assumed in driving horses (Koplik). The arms are pressed 
against the thorax and the thumbs are turned into the palms 
of the hand by the contracted fingers. Pressure upon the 
large nerve trunks and arteries of the extremities affected 
during the spasm will invariably bring on an attack. This 
sign is known as " Trousseau' ] s symptom" Another symptom 
obtained in tetany is known as Chvostetts symptoju, and con- 
sists of a contraction of the muscles of the face after tlfey 
have been tapped sharply. 

Older children who have been walking and feeding them- 



DISEASES OF THE NERVOUS SYSTEM. 491 

selves find it impossible to continue to do so. Even in the 
intervals between the spasms there is a tendency to have 
them recur from voluntary movements. 

The duration has been variously given as from several 
weeks to several days. In this respect it is similar to chorea, 
many cases promptly recovering, while others practically 
show the choreic tendency or its after-effects throughout life. 
The prognosis is good, being favorable as far as danger to life 
is concerned unless the attacks are accompanied by spasm of 
the glottis or general convulsions, or pronounced spasm of 
the respiratory muscles. Under these circumstances a fatal 
outcome may result. 

Diagnosis. — The carpo-pedal spasm of tetany is so charac- 
teristic that it cannot readily be confused with any other con- 
dition, especially when associated with laryngo-spasm. The 
other symptoms, indicating the increased irritability of the 
nerves, increased reflexes and Trousseau's and Chvostek's 
symptoms, serve to corroborate the diagnosis. Some authors 
go so far as to assert that laryngo-spasm is an incomplete form 
of tetany, as in many of these cases the latent symptoms of 
the disease, namely, Trousseau's and Chvostek's symptoms, 
can be elicited. When opisthotonos develops the matter be- 
comes more complicated, but the absence of fever and dis- 
turbances of consciousness and the tendency to interim ttency 
confirm the diagnosis of tetany. 

Treatment. — The constitutional condition must be cor- 
rected by an appropriate diet and hygiene, that directed for 
rickets being especially suitable. In fresh cases in infants I 
begin by excluding milk for twenty-four hours, giving only 
barley water. Then, if the child has been previously fed on 
sterilized food I put it on pure, raw milk, properly modified 
to conform to the age and the state of the digestion. 

The remedies most likely to do good are those exerting a 
direct influence upon the nutrition, especially upon that of 
the nervous system. According to Bartlett, there is no homce- 
pathic literature upon the subject, and he recommends Nux 



492 DISEASES OF CHILDREN. 

vomica and Secale as suggesting themselves symptomatically. 
A case of long standing coming under my care at the Chil- 
dren's Homoeopathic Hospital was promptly relieved by 
Magnesia phosphorica, 3X trit., so that it was able to feed 
itself and walk. The cure could not be attributed to nursing 
alone, as it had come from other institutions. The child was 
dismissed cured, but the subsequent history could, unfortu- 
nately, not be ascertained. Since then I have given this 
remedy several times, but the duration of the disease under 
proper management is so short that it is difficult to say how 
much can be attributed to a medicine. As a constitutional 
remedy, and to avoid recurrences, I employ Calcarea phos. 

AFFECTIONS WITH MOTOR DISTURBANCES: CHOREA. 

Chorea, or St. Vitus' dance, is one of the commonest nerv- 
ous diseases of childhood. It is a neurosis characterized by 
irregular, useless, involuntary muscular contractions in vari- 
ous parts of the body, usually of wide distribution, and asso- 
ciated with a loss of muscular tone and disturbed co-ordina- 
tion of voluntary movements. The onset is acute and the 
course pursues a sub-acute character. The relationship of 
chorea to rheumatism is one of its most noteworthy features. 

Etiology". — There are evidently two classes of chorea. In 
the one we can find no evidence of rheumatism or endocar- 
ditis, but must look upon the motor disturbances as arising 
from either malnutrition of the motor cells of the cortex or 
toxic irritation (possibly auto-intoxication), occurring in deli- 
cate and neurotic children usually as a result of prolonged 
indoor life and excessive pressure at school. For this reason 
we see so many cases developing in the spring of the year; in 
other words, toward the close of the school term. In every 
children's clinic the large number of pale, thin, ambitious 
children, mainly girls, that come regularly with symptoms of 
chorea in March and April stands in distinct contrast to the 
scarcity of these cases in the fall. 

Hodge has shown that as a result of fatigue the nerve cells 



DISEASES OF THE NERVOUS SYSTEM. 493 

shrink in size, their nuclei and nucleoli become shrivelled 
and the lenticular granules of the protoplasm, probably nutri- 
ent, disappear. While under ordinary conditions the cell is 
promptly restored to normal after a period of rest, a much 
longer time, and sometimes a protracted period of rest, is re- 
quired for this restoration in anaemic, neurotic children. 

Griesbach's interesting experiments with the esthesiometer 
have given valuable data in the study of school-fatigue in 
children. When this method of investigation shows in a 
given case that recuperation is sub-normal, we should accept 
the result as a danger-signal, for if fatigue is prolonged it be- 
comes cumulative and then complete recuperation is impossi- 
ble so long as the child is kept at school (La Fetra). 

In the other class of cases the etiologic factor is plainly 
rheumatism. In fact, the conditions may coexist or the 
chorea follow promptly upon an attack of articular rheuma- 
tism. Again, the frequent association of endocarditis with 
chorea — variously estimated by different authorities — points 
to the close relationship of the two affections. Indeed, Heub- 
ner (Kinderheilkunde, 1903) goes so far as to say that the 
etiology of chorea is closely related to all rheumatic poisons, 
not only to those producing acute articular rheumatism, but 
the affection may also develop on the ground of a gonorrhceal 
infection ; likewise in the wake of scarlet fever and other in- 
fections in which arthritis at times occurs. 

Streptococci have been isolated from the blood and nervous 
system in a few fatal cases of chorea by Westphal and by 
Wassermann ; tonsillitis has also been observed to precede 
attacks of chorea, as in rheumatism. 

The opponents of the rheumatic theory of the etiology of 
chorea have been misled to a certain extent by a failure to 
understand the clinical course pursued by rheumatism in the 
child. If we remember that rheumatic infection does not 
necessarily mean polyarthritis, but that certain forms of sore 
throat ; vague joint pains or pains in the muscles and ten- 
dons accompanied by fever ; growing pains and primary en- 



494 DISEASES OF CHILDREN. 

docarditis itself are all manifestations of acute rheumatism, 
or rheumatic fever in childhood, we will decide that a much 
larger number of our cases of chorea are rheumatic. Heub- 
ner, in fact, makes the rather sweeping statement that chorea 
is the commonest form of rheumatism in childhood. 

Chorea is also closely associated with a rheumatic family 
history. In the cases in which I was unable to ascertain definite 
symptoms of rheumatism in the child there was almost inva- 
riably a strong evidence of the disease in the parents or in 
other members of the family. From this it would seem that 
a common toxic agent exists which is capable of giving rise 
to choreic manifestations if it affects principally the cerebral 
cortex, and rheumatic manifestations if the articulations and 
serous membranes are attacked— an explanation advanced by 
Hirt and others. Indeed, we may observe both the manifes- 
tations of chorea and rheumatism to a marked degree in cer- 
tain severe cases of rheumatic fever, and the appearance of 
choreic symptoms in such cases offers a grave prognosis, as 
they indicate a high degree of toxaemia. 

A neuropathic family history is found in a large percentage 
of cases, and epilepsy, insanity or alcoholism in the parents 
are undoubtedly potent predisposing causes to chorea. In 
this respect sex also plays an important role, as girls are far 
more frequently affected than males. Fright is an exciting 
cause in many cases. No matter to which class the case may 
belong, this mental trauma acts as a precipitant of the symp- 
toms. 

The largest number of cases are seen between the ages of 
seven to twelve ; before the fifth year it is quite rare, and after 
puberty it usually disappears spontaneously, although cases 
have been observed in adults. This must not, however, be 
confounded with Huntingdon's chorea, which is a hereditary 
disease developing between the thirtieth and fortieth year, and 
presenting a most unfavorable prognosis. 

The pathology of chorea is still obscure. As the action of 
the toxins upon the cerebral hemispheres would in all proba. 



DISEASES OF THE NERVOUS SYSTEM. 495 

bility excite only vascular and nutritional changes they are 
difficult to demonstrate. The frequency of unilateral disturb- 
ances early in the course of chorea, the cessation of symptoms 
during sleep, the blunting of the mental faculties and the oc- 
casional psychic disturbances observed, indicate that the gray 
matter of the cerebral cortex is pre-eminently affected. Or- 
ganic changes in the structure of the brain may lead to the 
development of choreiform movements, especially lesions fol- 
lowing a cortical haemorrhage. The term "posthemiplegic 
chorea" has been applied to these cases, but the movements 
are, more strictly speaking, athetoid in character, usually uni- 
lateral, not ceasing during sleep, and associated with rigidity 
and other evidences of organic disease. 

The presence of capillars* emboli in the brain (corpora stri- 
ata) was seriously looked upon as the specific lesion in chorea, 
but this occurrence has been shown to be purely accidental, 
resulting from a complicating endocarditis, and by no means 
an essential element in the disease. 

Symptomatology. — The onset may be sudden or gradual. 
A severe fright may be followed within the course of a few 
hours or a day by evidences of extreme restlessness and a dis- 
position to jerk and twitch in various parts. Ludicrous grim- 
aces may be executed, and the child is unable to remain seated 
quietly in one position for any length of time. The arms are 
thrown into continuous irregular action and the legs crossed 
or shifted from one place to another. Voluntary actions are 
executed with difficulty, being characterized by extreme awk- 
wardness and futility of purpose; the extremities become 
weak, so that the child drops every article from its hands and 
stands in a relaxed, swaying position, readily stumbling or 
tiring out, while speech may become so indistinct and muf- 
fled from involvement of the tongue and muscles controlling 
the larynx (laryngeal chorea) as to render it most difficult of 
interpretation. 

A more gradual result is seen in those cases resulting from 
overpressure at school, anaemia following acute illness, or any 



496 DISEASES OF CHILDREN. 

other of the slower-acting exciting causes. The child will 
give indications of gradually-increasing restlessness and awk- 
wardness, the first condition resulting from the occurrence of 
involuntary muscular contractions, while the latter indicates 
disturbed co-ordination from the association of involuntary 
muscular contractions with all voluntary efforts. These phe- 
nomena may begin in one extremity or as a unilateral affec- 
tion, the first symptom being paralytic weakness. The entire 
body soon becomes involved, and the apparent paralysis may 
disappear or simply share in the general muscular debility. 
These cases are described as paralytic chorea, monoparesis 
being the most common type. Church (Church and Peter- 
son, Nervous and Mental Diseases) is of the opinion that 
many of these cases really belong to the neuritides or to a 
myelitis, or are combinations of these with chorea. 

The movements observed in the face are a twitching of the 
eyelids and distortion of the mouth. . The tongue exhibits 
marked choreic twitchings in the majority of cases, even in 
such where movements of the extremities are slight. Sachs 
{Nervous Diseases of Children) places especial diagnostic 
value on the movements of the tongue and associated facial 
action in propulsion of this organ, describing these combined 
movements as the "facies" of chorea. The tongue move- 
ments are slow and coarse, and propulsion of the tongue is 
attended with unnecessarily wide opening of the mouth, rais- 
ing of the eyelids and eyebrows, and catching of the tongue 
between the teeth through choreic movement of the masseters. 

The head may be turned from side to side and the shoulders 
alternately raised and lowered. The hands are alternately 
flexed and extended at the wrist, and the arms are' thrown 
about in an irregular and jerky manner in severe cases. At- 
tempts to control these irregular movements or to perform 
voluntary acts only intensify them, and the child may become 
unable to feed itself or execute other coordinate acts. When 
the child's hand is taken between the hands of the examiner, 
the irregular muscular contractions are readily felt. By 



DISEASES OF THE NERVOUS SYSTEM. 497 

directing the child to perform some voluntary act, the move- 
ments are demonstrated to the eye. The legs may be so 
affected by the muscular weakness and incoordination as to 
render it necessary to put the child to bed. x\lthough sleep 
may be so disturbed as to exhaust the child to the extreme, 
and the great restlessness render it necessary to protect the 
child against falling out of bed, still, in the majority of cases, 
the movements abate on lying down and disappear entirely 
during sleep. The latter symptom is pathognomonic of 
chorea, serving to distinguish it from other motor disturb- 
ances. 

The tempei'ature is normal in most cases; an elevation of 
several degrees should lead to a suspicion of rheumatism or 
endocarditis. The heart is affected in the majority of severe 
cases of chorea. The percentage of endocarditis reported by 
the various writers on the subject varies greatly. Heubner 
found a murmur in 53 per cent, of his cases, but this dees not 
necessarily indicate that all had endocarditis. In hospital 
cases the percentage is highest, because the severer cases 
come to the hospital. Nevertheless, I have had a number of 
bad cases in my hospital practice in which there was no en- 
docarditis. Out of forty cases personally observed during the 
last two years, ten had endocarditis. In two others a mur- 
mur was found, but it was considered purely functional. Of 
this series, fifteen gave a history of rheumatism. Osier ex- 
amined one hundred and forty cases two years after an attack 
of chorea and found evidence of organic heart disease in 
seventy-two of these patients. 

In older children mitral regurgitation is closely associated 
with chorea. Beside organic manifestations, a cardiac neu- 
rosis is also encountered, inducing a group of symptoms which 
disappear with the disease. Both arythmia and a systolic 
murmur may be present, simulating valvular disease; but the 
murmur varies from day to day in intensity, is not transmitted, 
the pulmonary second sound is not accentuated, and hyper- 
trophy does not take place. The condition has been called 



498 DISEASES OF CHILDREN. 

cardiac chorea, and is supposed to indicate irregular innerva- 
tion of the papillary muscles. 

The mental state of the child is one of irritability, mental 
lethargy with deficient memory and power of concentration, 
and it may even assume a maniacal type of disturbance. Al- 
though true mental derangement is rare, it is not unusual to 
observe a highly-exalted psychical state, especially with re- 
lapses or acute exacerbations in severe cases. The face be- 
comes flushed ; the eyes are brilliant and have a wild, staring 
expression ; there may be alternate crying and laughing or 
simply crying out, and the general condition becomes greatly 
aggravated. With proper management such outbreaks are 
only of short duration, but they may become of serious import 
when associated with fever and progressive exhaustion, even 
terminating in coma and death. This constitutes the choreic 
status, which, however, is fortunately seldom encountered. 

The course of chorea is quite variable. Although usually 
described as a self-limiting disease, it is, nevertheless, one 
which can be controlled to a marked degree by medication, 
whereby its course may be -materially shortened and the 
symptoms greatly moderated. On the other hand, although 
complete recovery is the rule, there are numerous instances 
in which as high as a dozen relapses have been noted, or in 
which the child carries the evidences of chorea to adult life. 
The average duration can be placed at about from two to 
three months, always remembering the possibility of relapses, 
especially in girls. In a series of dispensary cases reported 
by Bayley {Trans. Horn. Med. Soc. of Penn., 1896) the aver- 
age duration from the time of onset was 19.4 weeks, and from 
the time of beginning treatment it was 12.1 weeks. In pri- 
vate practice the course is considerably shorter than these 
statistics indicate. 

Diagnosis. — The main source of error in the diagnosis of 
chorea will arise from confusing it with the motor disturb- 
ances of such conditions as post-hemiplegic chorea and atheto- 
sis, which are postplegic movements associated with paralysis 



DISEASES OF THE NERVOUS SYSTEM. 499 

of cerebral origin, and those of Freidreictt s ataxia, multiple 
cerebrospinal sclerosis and hysteria. 

The history of the case, the facies of chorea, the charac- 
teristic movements and the association of rheumatic symptoms 
on the one hand and the absence of signs of an organic nervous 
affection on the other should render the differentiation easy. 

Treatment. — As soon as evidences of chorea are observed 
the child should be taken from school and every effort 
made to eliminate from its life all excitement and men- 
tal and physical strain. The child must be treated with 
patience and kindness. Parents should be impressed with 
the fact that it is utterly impossible for the child to control 
its movements, and that scolding or constantly calling the pa- 
tient's attention to his condition will only aggravate the symp- 
toms. Rest in bed is indicated in all grave cases or those of 
abrupt onset. Bartlett advises against all forms of physical 
exercise, but a sojourn in the country, with plenty of fresh 
air and out-of-door life, is of unquestionable benefit in cases 
of moderate severity. During convalescence I believe judi- 
ciously carried out exercises to be of great value. 

The diet is of importance. Remembering the rheumatic 
element in these cases, fats, especially cod liver oil and but- 
ter, are of decided value. The free use of meats should be 
interdicted, but milk, eggs, cereals and vegetables may be 
taken liberally. 

Extreme restlessness, insomnia and mental excitement call 
for a warm bath at bedtime. Hot milk is also a valuable ad- 
juvant in these cases. 

The remedies from which I have obtained the most posi- 
tive results are Bellado?tna, Causticum, Stramonium and 
Agaricus. Bartlett recommends Agai-icin in the second deci- 
mal trituration in all cases not presenting strong indications 
for any other remedy. 

Where rheumatic symptoms are prominent, Actea rac, 
Rhus tox. and Sulphur are frequently indicated and of value. 

In the choreic states I have found Bell, and Stramonium 
of service. 



500 DISEASES OF CHILDREN. 

Arsenicum, the chief remedy of the old school, adminis- 
tered in the form of Fowler's solution, and Ferrum are useful 
when anaemia and other conditions pointing to these reme- 
dies are prominent symptoms. 

Agaricus. — Spasmodic, jerky movements of the extremi- 
ties and frequent nictitation of the eyelids {Hyos.). Sensa- 
tion of coldness and tingling in various parts ; paralytic 
weakness of legs. The active principle of Agaricus is not 
Agaricin but Muscarin. Bayley speaks of it with praise. 
Personally my experience has been chiefly with Agaricus 
in the second and third decimal dilution and it. has done well 
as a routine remedy in the milder, non-rheumatic cases. 

Bell. — Great mental excitement ; delirium approaching to 
a maniacal condition ; the face is flushed and the eyes are 
brilliant and staring ; there is great difficulty of speech, and 
a sensation of dryness and choking in the throat. 

Stramonium should be given if Bell, does not promptly re- 
lieve these symptoms, and if there is an incessant throwing 
about of the arms and a highly frightened behavior of the 
child. 

Caust. — Paralytic chorea with speech defect. The child 
stands in a limp, relaxed condition ; it is hardly able to walk 
or dress or feed itself ; the voice sounds thick and unintelli- 
gible, and the tongue is protruded with difficulty. In such 
cases Causticum may be considered well-nigh a specific. In 
the last years I have been able to verify repeatedly the value 
of Causticum when these symptoms are encountered. 

Cimicifuga. — Rheumatic pains in the small joints; endo- 
carditis ; after suppression of menses. 

Cina. — Helminthiasis or intestinal indigestion. 

Coccul. — Right-sided chorea ; face puffed and bluish ; 
hands and feet look as if frozen; paralytic symptoms. — (C. 
G. R.). 

Hyos. — Constant twiching of the eyelids ; angular gyra- 
tory movements, with incoordination ; misses what he reaches 
for ; silly expression of face, smiling at everything he hears ; 
chorea after debilitating fevers. 



DISEASES OF THE NERVOUS SYSTEM. 501 

Ignatia. — Highly nervous temperament ; easily frightened ; 
starts at the slightest noise; irritable temperament. Mild 
cases, developing after fright. 

Mygale. — Constant turning of the head to the right side, 
occasionally dropping it on the shoulder. 

Nux vom. — Sensation of numbness in the affected parts ; 
frontal headache, constipation, indigestion, irritability and 
lassitude. 

Pulsatilla. — Chlorotic subjects; mild, tearful disposition ; 
functional cardiac disturbances. Chorea developing at the 
time of puberty. 

Stramonium.— Chorea developing after fright. The symp- 
toms are usually severe, and may approach the choreic state. 
(See belladonna.) The movements are pronounced, but there 
is not that degree of paresis calling for Causticum. 

Sulphur. — Protracted cases with frequent relapses ; rheu- 
matic family history ; after suppression of eruptions. Other 
constitutional remedies which may be called for upon purely 
diathetic indications are Calc. carb. and Phos., Mercurius, 
Phosphorus and Silicea. 

SPASMUS nutans; head-nodding with nystagmus. 

The syndrome of rhythmic movements of the head associ- 
ated with nystagmus is a peculiar condition occasionally en- 
countered in rachitic and otherwise poorly nourished infants. 
Of late this phenomenon has attracted considerable attention 
among pediatrists, and a number of cases have been reported 
in the literature from time to time. 

Nystagmus may be the only symptom, or it may be the 
first symptom, other nervous manifestations, namely, head- 
nodding and laryngismus stridulus developing later, as oc- 
curred in one of my cases. Blepharospasm may also be pres- 
ent (Amberg), and associated movements in the extremities 
(Ausch) and temporary loss of consciousness (Hadden) have 
also been observed. As a rule, the movements cease during 
sleep. 



502 DISEASES OF CHILDREN. 

The majority of cases occur in infants under one year. The 
early signs of rickets are usually present. There is no patho- 
logic lesion, but most probably the symptoms are due to irri- 
tation or exhaustion of the nerve centres for the muscles gov- 
erning these movements. Henoch has pointed out that the 
nuclei of the oculo-motorius and the nerves governing the 
movements of the neck are adjacent, and that, therefore, they 
are readily irritated simultaneously. In many cases there is 
no doubt as to the exciting cause, namely, keeping the child 
in a dark room with the eyes exposed to the bright light of a 
window, analogous to the etiology of miner's nystagmus. All 
my cases have occurred in dispensary patients from the poor, 
crowded districts. 

The prognosis is favorable, as the symptoms depend partly 
upon the underlying malnutrition or auto-intoxication which 
may be present in the case. The treatment is purely symp- 
tomatic, and is to be conducted upon the lines as laid down 
in the discussion of rickets. In congenital nystagmus, of 
course, the outlook is different, but here the symptoms exist 
from birth. I have not been in the habit of prescribing for 
the nervous symptoms alone, but have obtained the best re- 
sults when treating the underlying disturbance. 

HYSTERIA. 

Hysteria is a psychoneurosis combining cerebral insuffi- 
ciency with certain disturbances of the sympathetic nervous 
system, U A state in which ideas control the body and produce 
morbid changes in its functions" (Moebius). Almost any 
organic disease can be simulated by this peculiar nervous de- 
rangement, for which reason its recognition and proper under- 
standing are of the highest clinical importance. Children are 
by no means exempt from hysteria, and sex bears no etiolog- 
ical relationship to the disorder. Although it may be en- 
countered in early childhood, it is rare before the tenth year, 
and most prevalent at the period of puberty and adolescence. 
Heredity plays an important role, a neuropathic family his- 






DISEASES OF THE NERVOUS SYSTEM. 503 

tory being present in most cases. As exciting causes, emo- 
tional disturbances — especially fright, grief, jealousy, and 
minor traumatisms in which the mental shock occurring at 
the time of the accident is entirely out of proportion to the 
injury sustained — are inseparably linked with hysteria. In 
the latter instance suggestion also enters into consideration, 
being one of the strongest influences in exciting as well as in 
removing hysterical phenomena. Reflex irritations, such as 
tight and adherent foreskin or adherent hood of the clitoris* 
have been mentioned as exciting causes. To these must also 
be added the baneful influence of improper training and dis- 
cipline, bad habits and various debilitating illnesses. 

Symptomatology. — In reciting the symptomatology of hys- 
teria, the general attributes and characteristics of the disease 
will be outlined, after which the special symptoms and clin- 
ical types will be considered. The first are spoken of as the 
stigmata, while the latter are designated the accidents of 
hysteria. 

Stigmata. — The mental condition is characterized by di- 
minished will power, loss of memory and lack of determina- 
tion, and indecision. Impressionability and irritability char- 
acterize the temperament. These subjects are very suscep- 
tible to suggestions, and the mood vacillates between sadness 
and gayety, uncontrollable paroxysms of alternate laughing 
and crying being a frequent occurrence. 

Disturbances of sensibility are encountered as complete or 
partial cutaneous anaesthesia, or hyperesthesia in certain 
localities. It is usually found in parts which are paralyzed, 
a hemiplegia with anaesthesia being strongly indicative of 
hysteria. Irregular islets of anaesthesia are likewise charac- 
teristic of hysteria. The area of anaesthesia does not corre- 
spond with the distribution of special nerve trunks or to the 
areas of sensation supplied by the different spinal segments, 
but seems to conform rather to the cortical representation of 
sensory areas. The mucous membranes may be anaesthetic 
and the special senses become perverted or abolished, leading 



504 DISEASES OF CHILDREN. 

to disturbance of sight, hearing, etc., or sudden blindness or 
deafness. The throat may become anaesthetic, so that we can 
irritate the fauces without producing gagging. Likewise, 
anaesthesia of the nose, conjunctiva, larynx, etc., is to be en- 
countered. The reflexes are not disturbed, as they are in 
organic lesions associated with anaesthesia. 

The motor disturbances to be observed are a general retar- 
dation of voluntary movements and muscular weakness and 
incoordination. This is explained by the presence of anaes- 
thesia and loss of muscular sense and of the power of mental 
concentration. 

To the milder forms of spasmodic affections, belong notably 
globus hystericus; hysterical cough, hiccough and glottic 
spasm ; spasm confined to certain muscle groups, notably those 
of the neck. 

The diathesis of contracture (Charcot) is a tendency to 
rigidities and contractures, which can be demonstrated by in- 
ducing a forcible flexion or extension in a limb, or by irritat- 
ing the muscles by deep massage or by means of the faradic 
current. 

Accidents. — To the accidents of hysteria belong certain 
transitory disturbances manifesting themselves as convulsive 
seizures {grand attacks ; hystero-epilepsy), or as motor and 
sensory disturbances of major degree, closely simulating a 
variety of organic diseases. 

Grand attacks belong to the rarer forms of hysteria in 
childhood ; but as they bear a superficial resemblance to epi- 
lepsy, they will be considered in full. The attack is preceded 
by depression of spirits and a sensory aura, most commonly 
the globus hystericus. This is described by the patient as 
the sensation of a ball rising into the throat and is due to 
spasmodic contractions of the pharynx and oesophagus. A 
general tonic spasm, which persists for a few minutes, marks 
the first stage of the attack. The child lies stretched out, 
with the limbs extended and rigid, the fingers and toes being 
flexed. Slow, rigid movements of wider range executed by 



DISEASES OF THE NERVOUS SYSTEM. 505 

the arms, and flexion and extension of the feet, may be ob- 
served during this stage. The jaws are tightly closed, and 
respiration is slow and irregular or entirely suspended. The 
face assumes a bloated appearance, and the veins of the neck 
are prominent and swollen. 

The clonic stage is ushered in by short, jerky movements 
involving the face and extremities. These movements in- 
crease in severity, but do not assume the regular clonic type 
of epilepsy, being more irregular and of a struggling charac- 
ter. Respiration becomes interrupted and sobbing. Biting 
of the tongue is rare, as is also involuntary defecation and 
micturition. After the course of a few minutes the move- 
ments cease abruptly, and a period of resolution or repose 
sets in — a condition simulating sleep. This may end the 
attack, or be succeeded by the period of clownism, during 
which the patient becomes fixed in a variety of rigid postures. 
Extreme opisthotonos is a common position observed in hys- 
teria. A phase of large movements now follows, in which 
the subject may cry out in fear or rage and strike or bite at 
those about him. Peculiar sounds are sometimes uttered re- 
sembling, for instance, the barking of a dog, and, when asso- 
ciated with the above symptoms, constitutes spurious hydro- 
phobia. 

The period of passional attitudes observed in adults is very 
rarely seen in children. The period of delirium, in which 
the child sobs and pleads in a pitiful manner, or expresses 
various hallucinations, often terminates the attack, after con- 
sciousness is restored. 

Motor accidents occur as paralysis and contractures. They 
are usually of sudden onset, as the result of fright or 
injury ; less commonly they develop gradually. Hysterical 
paralyses correspond in their general characteristics with cen- 
tral paralyses — there is loss of will-power to move the 
affected member. The legs are more frequently affected than 
the arms. There may be monoplegia or paraplegia, which 
may be followed by contractures, or the palsies may alternate 

33 



506 DISEASES OF CHILDREN. 

with contracture. The paralyzed part is frequently anaes- 
thetic, and the anaesthesia corresponds to the cortical distri- 
bution of sensation, not being confined to one or more nerve 
trunks, as in peripheral nerve and spinal affections. 

In hemiplegia the face escapes, with the exception of the 
eye-muscles, which are at times affected. Anaesthesia is com- 
mon, while in organic cerebral hemiplegia it is rare. Again, 
the contractures of hysteria partake more of the nature of 
spasmodic voluntary resistance, and atrophy never takes place 
excepting as a slight amount of wasting resulting from non- 
use. Iyoss of power is not absolute, and the degree of paraly- 
sis may vary from day to day. The gait also differs from 
that observed in cerebral palsies in that the leg is dragged 
along in a limp condition, not being swung out in a lateral 
direction, by which the foot is made to describe an arc. 

Paraplegia may exist as a purely ideational palsy, render- 
ing walking impossible, or there may coexist disordered func- 
tion of the cord, indicated by increased knee-jerk, spurious 
ankle-clonus, retention of urine and spinal tenderness. 

Contractures may exist independently or in association with 
paralysis and anaesthesia. The extremities are most fre- 
quently affected. When the hands and feet are affected, the 
fingers and toes are flexed. With involvement of the larger 
joints there is extension, so that the arm and leg are held 
out straight. Contractures may occur in monoplegic, hemi- 
plegic or paraplegic distribution. In deep sleep the rigidity 
usually disappears. 

Astasia abasia is a condition of lost co-ordination for walk- 
ing and standing. It is produced by alternate contractions 
of antagonistic groups of muscles. 

Hysterical coxalgia is a most important subject presenting 
itself for consideration to the paediatrist. No doubt, the 
numerous cases of so-called reflex paralysis and coxalgia re- 
ported as having been cured by circumcision belong to this 
category. Apparently, every subjective and objective symp- 
tom of hip-joint disease has been mimicked by this neurosis > 



DISEASES OF THE NERVOUS SYSTEM. 507 

and nothing short of a careful examination under an anaes- 
thetic will serve to differentiate a pronounced case from true 
hip-joint disease. This holds good for other joint affections 
in which fixation and pain without any objective signs are 
present. In order to expel all doubt it may become neces- 
sary in an obscure case to resort to the tuberculin test. 

Tremors and rhythmical spasms, the latter simulating 
chorea, are other motor accidents deserving mention. 

Sensory Accidents. — A pseudo-meningitis is occasionally 
encountered, and is distinguished from true meningitis by the 
history of the case, the absence of slowing or irregularity of 
the pulse and active pupils. In other respects it bears a close 
similarity to meningitis, presenting intense headache ; vom- 
iting ; fever; vasomotor streaks (laches cerebrates), and rigid- 
ity of the neck and extremities. Recovery, however, takes 
place, and a careful study of the patient reveals other evi- 
dences of hysteria. 

Spinal tenderness may be confined to the region of a few 
vertebrae and closely simulate Pott's disease ; but if the 
patient's attention can be detracted momentarily quite a con- 
siderable amount of pressure will be borne without causing 
pain. 

Visceral Accidents. — Disturbances in the respiratory tract 
show themselves as aphonia, usually developing suddenly 
after a fright, the voice being lost, but cough persisting ; 
dyspnoea, due to laryngeal or diaphragmatic spasm ; tachyp- 
ncea, sudden attacks of extremely rapid breathing, presenting 
alarming symptoms, without the evidence of physical signs 
to account for the same, and pulmonary congestion. The lat- 
ter is rare. It may produce cough with bloody expectoration, 
and simulate phthisis. 

In the digestive tract, vomiting, globus hystericus, oesopha- 
geal spasm, anorexia and obstinate constipation are to be ob- 
served. 

Frequent urination of large quantities of pale, limpid urine 
or complete anuria, sometimes retention of urine, are the dis- 
turbances encountered in the urinary tract. 



508 DISEASES OF CHILDREN. 

Vasornotor and Trophic Accidents. — Cutaneous hemorrhages 
and ga?igrene of the skin are among the rare hystero-neu roses, 
while erythema and vesicular eruptions are commonly met 
with. Der7natographism is occasionally observed. 

Muscular atrophy and fibro-tendinous contractures are rarely 
well marked, although they may develop to a sufficient de- 
gree to require tenotomy in cases of long standing. 

The muscles do not give the reaction of degeneration, 
although they may be partially atrophied and show a quanti- 
tative loss in electrical excitability. 

The prognosis of hysteria is especially favorable in chil- 
dren, as they are readily influenced by suggestion, and, if the 
proper surroundings and intelligent treatment can be pro- 
vided, recovery is generally comparatively rapid. The acci- 
dental disturbances, as a rule, disappear spontaneously after a 
variable period of months or years, or they may be purely 
transient. The mental state can, however, seldom be im- 
proved beyond a certain limit, and the hysterical tempera- 
ment will persist throughout life in the majority of cases, 
even reflecting itself upon the offspring. 

Sensory accidents are stubborn in their course, bringing 
considerable suffering to the patient and much anxiety to the 
friends and attendants. The spasmodic manifestations can 
usually be cured promptly if the patient can be taken from 
their parents and kept under intelligent care. 

In the diagnosis much importance is to be attached to a 
recognition of the stigmata of hysteria ; in other words, the 
hysterical temperament, in conjunction with the emotional 
origin of the ailment and the polymorphous and changeable 
character of the manifestations. Beside this, the differential 
features serving to separate hysterical from organic diseases, 
as pointed out in the symptomatology, should serve in leading 
to their recognition. This applies particularly to paralytic 
affections, which are of especial interest to the podiatrists. 

In coxalgia an anaesthetic may be required to remove any 
doubt in establishing the condition under consideration. 



DISEASES OF THE NERVOUS SYSTEM. 509 

Hystero-epilepsy is rare in children, and its differentiation 
from epilepsy has been discussed in the article upon that 
subject. 

Treatment. — The general management of hysteria resolves 
itself into removing all exciting causes, isolation being the 
most effectual method for this purpose ; attending to the re- 
moving of all sources of reflex irritations, such as phimosis 
and errors of refraction, and building up the constitution by 
means of regular calisthenic exercises, a highly-nutritious diet 
and a liberal amount of sleep. 

Suggestion presents itself as a most potent agent in restor- 
ing the patient's confidence and overcoming the various dis- 
turbances which have an imaginary origin. In managing 
cases of paralysis our main effort must be in the direction of 
promising the patient that the line of treatment employed 
will bring positive results. To emphasize this suggestion 
such adjuvants as massage and electricity are employed with 
benefit. This does not, however, apply to ill-managed cases 
of long standing, in which the surgeon's aid must be sought. 

The beneficial results following upon even the most trivial 
surgical measures resorted to in hysterical subjects is a note- 
worthy clinical fact, which often can be taken advantage of 
as a justifiable means of treatment. 

Medicinal treatment serves a twofold purpose, namely, by 
augmenting the force of the suggestions and also by improv- 
ing the patient's general condition and correcting the various 
disturbances in the nervous system and other localities. It is 
needless to mention the close relationship existing between 
neurasthenia and hysteria in children, and, therefore, remedies 
which will improve the nutrition of the nervous system can- 
not fail to influence the hysteria. Such remedies as Picric 
acid, Calcarca ear/?., Silicea and Phosphorus exert a potent 
influence in this direction. 

Remedies possessing notably hysterical symptoms are Ig- 
natia, Hyoscyamus, Aconite, Asafoetida, Moschus and Valerian. 
The efficacy of drugs in such conditions as hysterical palsy 



510 DISEASES OF CHILDREN. 

and hystero-epilepsy is doubted by many. Arndt {Practice of 
Medicine) expresses the opinion that " they are often helpful, es- 
pecially in times of great emotional excitement." If that were 
the case, a remedy should be useful as well at any other time 
when its symptoms are present, even if the disease be hysteria. 
An unfortunate error often made in managing hysterical 
subjects is to look upon them as simply imagining their 
troubles and, therefore, requiring no treatment. Nowhere 
more than in hysteria does it require firm yet gentle supervi- 
sion and persistent and encouraging suggestion to lift the 
patient out of his imaginary fears and afflictions. With a 
hysterical child we have a campaign of education before us 
which must be carried out up to the time of adolescence. 
The parents are often these children's worst enemies, and iso- 
lation is, therefore, one of the first steps in the treatmeut of a 
confirmed case. 

PARALYTIC AFFECTIONS: CEREBRAL PALSIES. 

The cerebral palsies of childhood comprise a group of con- 
ditions which may be either of intra-uterine onset, or which 
are acquired during parturition or at a still later period. 
Cases of intra-uterine origin are usually developmental in 
character, and to this group belong porencephalia, agenesis 
corticalis and other defects, although evidences of haemor- 
rhage and sclerotic changes, as a result of traumatism, foetal 
meningoencephalitis and syphilis, have been observed in 
rare instances. 

In birth-palsies, haemorrhage is the primary lesion. It 
occurs frequently in protracted labors, and although forceps- 
pressure may directly induce a haemorrhage, still it does not 
play as important a role as long-continued compression of the 
head in the pelvic straits or within the uterus. It has also 
been supposed that undue pressure upon the trunk during the 
extraction of a breech presentation maybe the direct cause for 
the rupture of a bloodvessel in the brain. The bleeding takes 
place from the capillaries and veinules of the pia mater or 



DISEASES OF THE NERVOUS SYSTEM. 511 

choroid plexus in most cases, more rarely from the longitu- 
dinal sinus and veins, and almost never from an artery. 
Venous congestion attending compression of the cord and 
asphyxia may give rise to a pial haemorrhage, but the weight 
of evidence is in favor of attributing the majority of cases of 
asphyxia neonatorum to haemorrhage. A new-born infant 
therefore, with pallid asphyxia should be looked upon as 
most likely an apoplectic one unless good reasons for some 
other cause are at hand. 

Where the amount of blood-extravasation is not sufficient 
to cause death, it ultimately is absorbed or becomes organized 
with consequent sclerosis of adjacent areas of brain-substance 
and developmental retardation. The symptoms attending 
such a condition .will naturally depend on the locality affected. 

The cerebral palsies encountered later in child-life are the 
result of either haemorrhage, embolism or thrombosis. A 
cerebral abscess or tumor may likewise cause definite para- 
lytic manifestations, but in their etiology and clinical course 
they differ distinctly from the foregoing conditions. Haemor- 
rhage at this period of life is more frequently meningeal than 
cerebral. It may result from traumatism, arteritis, or from a 
sudden and severe venous congestion of the brain occurring 
during a convulsion or during a paroxysm of whooping-cough. 
I have seen two cases resulting directly from whooping-cough. 
The convulsion is probably the result of the haemorrhage, and 
not vice versa. 

Birth-palsies are usually bilateral, that is, diplegic or para- 
plegic, while the later palsies are most frequently hemiplegia 
Sometimes hemiplegia attacks an infant in apparently perfect 
health, the symptoms coming on with fever, followed by con- 
vulsions and hemiparalysis. Struinpell advanced the theory 
that these cases were infectious, and that an acute inflamma- 
tory process in the cortical gray matter of the motor area 
was the primary lesion. Pathologically and etiologically it 
was supposedly similar to poliomyelitis, for which reason he 
named it "Acute Polioencephalitis of Infants ." Osier and Sachs 



512 DISEASES OF CHILDREN. 

from a study of a number of these cases, question the correctness 
of this view, claiming that the lesions are probably always 
haemorrhagic. In spite of the opinion of the high authorities 
just quoted, I believe with Mills, Holt and others that we do 
encounter cases whose mode of onset and clinical course cer- 
tainly appear to bear out Strumpell's theory of an inflammatory 
lesion of infectious origin. Again, I believe that in some 
cases the symptoms are purely toxic, and we know that in 
adults apoplectiform attacks without haemorrhage frequently 
occur as a phase of uraemia. In such cases we are surprised 
to find no gross lesion at the autopsy. Recently a colored 
child, two years old, previously perfectly healthy, was brought 
to my clinic for convulsions occurring daily and confined to 
the left side of the body. There was hemiplegia, although 
considerable improvement was manifest. The condition de- 
veloped suddenly six weeks previous, the child being seized 
with these one-sided convulsions and temporary loss of con- 
sciousness, followed by hemiplegia. There was also fever 
continuing for several days. Why haemorrhage should occur 
in such a case is hard to explain, but an encephalitis is quite 
conceivable. 

Abscess is most frequently secondary to suppurating otitis 
media. 

Sinus thrombosis results from extreme anaemia in conjunc- 
tion with feeble heart's action occurring during exhausting 
illness, or from infection from the middle ear. In such cases 
thrombosis of one of the lateral sinuses, with its characteristic 
symptoms, results. Embolism is most frequently associated 
with endocarditis, only in rare instances originating from 
clots which have formed in the left auricle or elsewhere. 

Symptomatology. — The lesions just enumerated may. be 
productive of a variety of manifestations, for which reason we 
may encounter either hemiplegia, diplegia, paraplegia or mon- 
oplegia in these cases. The last two are rare, especially mon- 
oplegia, and paraplegia is frequently only apparent — a careful 
examination also revealing evidences of paralysis in the arms, 
together with mental deficiency. 






DISEASES OF THE NERVOUS SYSTEM. 513 

The mental condition is impaired and the head is usually 
small or irregular of form. Epilepsy develops in about one- 
half of these cases, assuming the true degenerate type of the 
disease. 

Diplegic cases are congenital, or result from injuries sus- 
tained during parturition. As above stated, the lower ex- 
tremities are most markedly affected, and athetosis is a promi- 
nent symptom. 

The case shown in the illustration, which is a very typical 
one, did not have athetoid movements. The child was men- 
tally deficient, but there had been no convulsions. Lack of 
mental development can be traced back to the earliest period 
of infancy and on account of the spasticity of the legs they 
do not learn to walk until very late. The rigidity in both 
arms and legs varies in degree ; when pronounced it reminds 
one of the resistance encountered in bending, a piece of lead > 
for which reason it has been described as " lead-pipe rigidity." 
Together with this there is a crossing of the lower extremi- 
ties due to adductor spasm and a tendency to equino-varus. 
The gait is, therefore, extremely difficult or impossible, and 
the hands are usually not well under control, being entirely 
helpless when athetosis is marked. A type of congenital 
diplegia resulting from defective development of the pyra- 
midal tracts in the brain and cord, seen in underdeveloped or 
premature children, has been described by Little, of London 
{Little's Disease). They are not deficient in mind, and the 
spastic condition usually improves with the development of 
the nervous system. 

Sachs (New York Medical Jour., May, 1896) has reported 
a series of cases of congenital cerebral agenesis occurring as 
a family disease, in which amaurosis, progressive debility and 
a fatal termination are the clinical features. More or less 
diplegia, with spasticity, is usually present. A number of 
these cases is reported in the literature under the name of 
u - luiaurotic Family Idiocy." 

The prognosis is unfavorable in all cases, but especially in 



514 



DISEASES OF CHILDREN. 



the diplegic forms, in which little can be done aside from im- 
proving the child's general condition by means of massage 
and faradism, or by surgical measures when necessary. The 
proper training of such cases is, however, of the greatest im- 
portance, through which means both the mind and body may 
be most wonderfully improved. 

In recent cases of hemiplegia the child must be dealt with 
purely symptomatically, and remedies are of decided use 




FIG. 49. — A CASE OF CEREBRAL DIPLEGIA IN A CHILD TWO 

AND ONE-HALF YEARS OLD, SHOWING SPASTIC 

RIGIDITY OF ARMS AND LEGS. 



here. Massage and faradization of the extensor muscles, and 
mechanical contrivances to overcome contractures, are gener- 
ally useful later on. Arnica, Kali hydrojod and Sulphur are 
aids in absorbing the i hemorrhagic extravasations, while 
Causticurn, Cocculus and Cuprum frequently exert a beneficial 
influence upon the paralytic symptoms. 



DISEASES OF THE NERVOUS SYSTEM. 515 

ACUTE ANTERIOR POLIOMYELITIS J INFANTILE SPINAL 
PARALYSIS. 

Poliomyelitis is perhaps the commonest form of paralysis 
encountered in childhood and, as the name implies, is an in- 
flammatory infection of the spinal cord, the lesion being a 
focal one and practically confined to the gray matter consti- 
tuting the anterior horns. The acute form is almost exclu- 
sively a disease of childhood, being most frequently encoun- 
tered in the later period of infancy. Poliomyelitis is occa- 
sionally encountered in adults, and then usually assumes a 
subacute type. 

Regarding the etiology nothing definite is known, but, 
judging from the clinical course of the disease, namely, rapid 
onset, with fever and other constitutional disturbances, its 
great predilection for the age of childhood, and the frequency 
of endemic and epidemic outbreaks — we are justified, in the 
present state of our knowledge, in classing it among the in- 
fectious diseases. 

Pathology. — The site of predilection is the cervical or 
lumbar enlargement of the cord and the inflammatory process 
extends into the anterior horns by way of the median branches 
of the ventral spinal artery. The toxine responsible for the 
lesions excites either a focal haemorrhagic myelitis, or the 
initial lesion may be embolism or thrombosis of one of these 
arteries (Marie). The multipolar cells of the anterior horn 
undergo atrophy and the inevitable result is paralysis and 
atrophy of the muscular fibres supplied by these nerve cells. 
In old cases the horn appears shrunken in size and inflamma- 
tory tissue occupies the place of the multipolar cells. 

Symptomatology. — The onset is rapid, with fevei of a 
moderate degree and some constitutional disturbances, even 
delirium and convulsions having been observed, or the symp- 
toms are so slight as to escape notice, and the child develops 
an extensive paralysis, without any apparent cause for the 
same being ascertainable. The stage of invasion, therefore, 



516 DISEASES OF CHILDREN. 

varies from a few hours to several days, and is of little diag- 
nostic value.. 

The paralysis is usually of extensive distribution in the 
beginning ; but as improvement sets in the paralysis becomes 
limited to those regions which have been most seriously af- 
fected, in which muscular atrophy also develops. With the 
onset of paralysis local tenderness in the limbs may be noted. 
The paralysis rapidly increases, remains stationary for a 
period of a week or two, after which it rapidly improves in 
certain regions, while in others prominent disability remains 
and wasting of the muscles sets in. 

The reflexes are lessened or abolished, according to the ex- 
tent of the paralysis, but control over the sphincters is rarely 
lost, such an occurrence indicating a grave outlook. The 
alteration in the electrical reaction of the muscles manifests 
itself as the reaction of degeneration. The growth of bones 
may be greatly retarded through involvement of their trophic 
centres in the cord. 

The distribution of the permanent paralysis varies greatly 
in individual cases. It may involve one or more extremities 
or remain confined to a few muscles of an extremity. The 
lower extremities are most frequently affected, but seldom 
equally. In the leg the most common deformity encoun- 
tered is talipes equinus with flexed leg, resulting from wast- 
ing of the extensor muscles. In the upper extremities the 
deltoid, the extensors of the wrists and the inter osseii are 
most frequently affected. 

The prognosis is unfavorable in so far as recovery of function 
in the paralyzed and atrophied parts is concerned, although 
there is seldom danger to life. Reaction to faradic stimulation 
is always a favorable sign, even when the muscles have failed 
to respond to this test earlier in the disease. Early loss of 
the same, however, indicates a permanent paralysis in most 
instances. 

Diagnosis. — The diagnosis of both the early as well as the 
late manifestations of poliomyelitis anterior may be beset 



DISEASES OF THE NERVOUS SYSTEM. 517 

with difficulty. Until paralysis is well developed, the disease 
cannot be positively recognized, and then it may be con- 
founded with rachitic pseudo-paralysis, multiple neuritis and 
cerebral palsy. The latter is of abrupt onset, is ushered in 
by convulsion, and the paralysis is one-sided and uniform. 
Besides, the reflexes are increased in a central lesion while 
in poliomyelitis they are abolished. In neuritis the onset is 
more gradual as a rule and there is pain, together with per- 
sisting tenderness, along the nerve trunks. There is never 
the atrophy seen in poliomyelitis. Epidemics have been ob- 
served in which there were cases of peripheral as well as 
spinal paralysis. The pronounced muscular atrophy of polio- 
myelitis, therefore, together with the reaction of degeneration 
and the history, are the features of poliomyelitis by which it 
can be differentiated from other forms of paralysis. 

The Idiopathic Muscular Dystrophies bear a close outward 
resemblance to the late manifestations of anterior poliomye- 
litis. They have been divided into a variety of clinical types, 
but are all closely related both etiologically and pathologi- 
cally. The main point' of distinction between these myopa- 
thies and poliomyelitis is their slow and progressive develop- 
ment, the symmetrical distribution of the atrophic changes, 
and the strong hereditary element and developmental factor 
in their etiology. 

The pathological changes observed in progressive muscular 
atrophy take place primarily in the muscles themselves, and 
the various clinical types of the disease really come under one 
and the same heading from the pathological standpoint (Erb). 
The muscle-fibres at first become hypertrophied, undergoing 
subsequent atrophy. The connective tissue is slightly in- 
creased. In isolated cases degenerative changes have been 
observed in the cells of the anterior horn (chronic poliomye- 
litis). 

The following types have been described : 

The Juvenile Type of Erb. — In this form the muscles of the 
arms and shoulders are mainly affected. 



518 



DISEASES OF CHILDREN. 



The Facio-scapulo-humeral Type of Landousy-Dejerine (In- 
fantile Form of Duchenne\ in which the face, together with 

the arms and shoulders, are affected. 

The Peroneal Type of Charcot and Marie, in which the 

peroneal muscles become atrophied. This may be followed 

by atrophic changes invad- 
ing the legs, trunk and upper 
extremities, and there is evi- 
dence of cord-lesions asso- 
ciated with the atrophy, 
showing itself as fibrillary 
twitching and reaction of 
degeneration. 

Pseudohypertrophic Para- 
lysis is a disease of early 
childhood, most frequently 
seen in boys, characterized 
by enlargement of the calves 
and buttocks, associated with 
atrophic changes. The mus- 
cles finally shrink, present- 
ing the same condition as 
the other forms of atrophy. 
The characteristic symptoms 
produced are a waddling 
gait; difficulty of climbing 
up stairs and great awkward- 
ness ; enlargement of the 
legs and buttocks ; lordosis ; 
inability to arise from the 
ground without the aid of 

the hands. In order to attain the erect position the child 

supports the hands on the anterior surface of the thighs and 

gradually pushes himself upright (Fig. 50). 

Treatment. — The child should be disturbed as little as 

possible, not interfering with ill-judged applications of fara- 





FIG. 50.— CLIMBING UP THE THIGHS 
IN PSEUDOHYPERTROPHIC PARA- 
LYSIS (GOWERS). FROM 
BARTEETT'S DIAGNOSIS. 






DISEASES OF THE NERVOUS SYSTEM. 519 

dism to the affected limbs during the acute stage, but wrapping 
them in cotton and enjoining absolute rest. — (BartlETT.) 

Later in the disease electricity proves of decided benefit. 
If the muscles do not respond to the faradic current the gal- 
vanic should be employed. The object is to produce muscu- 
lar contractions in order to improve the nutrition of the 
muscle and restore function as far as that is possible. Passive 
movements and massage should be added to the treatment in 
order to overcome deformities. When once established, these 
will require surgical measures to correct them. The disa- 
bility in a joint resulting from atrophy of one of the muscles 
either flexing or extending the same is often satisfactorily 
corrected by a properly adjusted brace, which not only sup- 
ports the joint but also prevents deformity. 

The remedies indicated in the early stages are such as will 
control the inflammatory condition, with the hope of lessen- 
ing the secondary destructive changes. Aeon., Bell., Bry., 
Gels., and Rhus tox. should be studied and carefully differen- 
tiated if there is a sufficiency of symptoms to prescribe upon. 
Otherwise, Bell, should be given the preference. Mercurius 
may be given with a view of absorbing exudation as promptly 
as possible. Plumbum is indicated at a later period. "The 
symptoms of chronic lead-poisoning correspond very closely 
with the symptoms of poliomyelitis." — (C. G. R.) It has 
seemed to me that the administration of Cdusticum has in 
some cases at least improved the tone of the muscles after 
the condition had come to the point of standstill. 

FAMILY ATAXIA. 

Family ataxia, also known as Friedreich } s disease, occurs 
as a family disease, several or all of the children of a family 
being attacked by a degenerative process of the posterior and 
lateral columns of the spinal cord as a result of teratological 
defects in its structure (neurogliar sclerosis). The first symp- 
toms usually make their appearance shortly before puberty, a 
period at which the processes of growth and nutrition are 



520 DISEASES OF CHILDREN. 

taxed to their utmost. When there are successive in a family 
they usually develop at a progressively increasing earlier 
period of life. An acute infectious fever may also hasten the 
development of symptoms, leading to its occurrence in early 
childhood. 

Hereditary cerebellar ataxia of Marie is characterized by a 
similar defective condition involving the cerebellum ; but it 
develops after puberty, and is accompanied by pronounced 
choreiform movements, increased deep reflexes, and optic- 
nerve atrophy, symptoms not belonging to spinal ataxia. 

Symptomatology. — One of the earliest symptoms noticed 
is an awkwardness in the legs, marking the beginning of the 
ataxia. Later the arms become involved. There is first un- 
steadiness in walking and standing, the child sways from side 
to side in attempting to maintain its equilibrum. As the 
muscular sense is not lost, the condition depending entirely 
upon incoordination, no increased difficulty in standing is 
noticed when the eyes are closed. The ataxia is associated 
with gradually increasing loss of power. The knee-jerk is 
lost early in the disease. This distinguishes it from the 
cerebellar variety, in which there is also at times an ankle 
clonus. 

Disturbances of speech develop as incoordination becomes 
general. The speech is irregular and jerky, and lacks modu- 
lation and rhythm. 

Nystagmus may develop later in the disease, being espe- 
cially noticed with lateral rotation of the eyes. The expres- 
sion is one of apathy and indifference, although the intelli- 
gence is not impaired early, but it becomes more or less 
retarded with the progress of the case, as does also the phys- 
ical development. Shortening of the foot, with exaggerated 
plantar arch and retraction of the great toe {club-foot and 
/iammer-toe), is a common deformity of family ataxia. An- 
other deformity is dorso-lumbar scoliosis. These deformities 
may develop before ataxia becomes pronounced, and consti- 
tute an early sign of the disease. 



DISEASES OF THE NERVOUS SYSTEM. 521 

The course is that of a progressively-increasing and hope- 
less malady, but remissions or aggravations may take place. 
There is nothing in the disease itself to cause death, for which 
reason the person so afflicted may live to adult life. 

Isolated cases are to be differentiated from cerebellar ataxia, 
chorea and multiple {insular) sclerosis. In the latter there is 
characteristically scanning speech, spastic gait and intention 
tremor. 

HEREDITARY SPASTIC PARAPLEGIA. 

This is a rare disease, first described by Striimpell, which 
develops in early childhood and pursues a progressive course. 
The pathologic findings are degeneration of the lower part of 
the pyramidal tracts. There is no cerebral involvement, con- 
sequently no history of birth injury or convulsions during in- 
fancy followed by paralysis, and the patients do not show 
evidence of mental deficiency nor do they become epileptic, 
as in the cerebral diplegias and paraplegias resulting from 
haemorrhage. Although the symptoms may not develop until 
adult life, still there seems to be no doubt that it is a terato- 
logical defect in the upper motor neuron. The symptoms are 
marked by spasticity and hypertonus of the muscles of the 
lower extremities, without sensory disturbances or involve- 
ment of the sphincters. The reflexes are increased. Bayley 
{four. Xerv. and Ment. Diseases, Nov., 1897) reported a series 
of cases in which the disease was traced back through five 
generations. The pathological findings are those of a de- 
generative process in the pyramidal tracts, the direct cerebel- 
lar tract and the columns of Goll. 

The course is slow and progressive. 

SYRINGOMYELIA. 

Syringomyelia is a disease of the spinal cord in which 
the spinal canal becomes pathologically enlarged as a re- 
sult of gliomatous infiltration, which subsequently breaks 
down. By the same process new canals of considerable length 
34 



522 DISEASES OF CHILDREN. 

may be formed within the gray matter of the cord. Although 
a rare disease in childhood, still it has occasionally been en- 
countered in young subjects. As to its etiology nothing 
definite is known, excepting that embryonal neurogliar tissue 
degenerates or becomes the seat of haemorrhage. 

The symptoms resulting from a central myelitis or from a 
haemorrhage into the cord — the latter, at times, occurring dur- 
ing parturition — cannot be distinguished from those belong- 
ing to glioma. 

Symptomatology. — The disturbances of syringomelia may 
be divided into several groups. Involvement of the sensory 
pathway in the gray commissure and posterior horns and 
columns gives rise to loss of pain and heat perception, with- 
out, however, loss of the tactile sense. This anaesthesia may 
be so complete and extensive as to render the patient in- 
sensible to almost any kind of pain and expose him to many 
dangers. 

Motor disturbances develop later than the sensory, and pre- 
sent paralysis of groups of muscles of a limb, usually becom- 
ing bilateral and accompanied by trophic changes. The reac- 
tion of degeneration is present. These symptoms indicate 
involvement of the anterior horns and pyramidal tracts. 

Vasomotor disturbances, cyanosis, coldness, cutaneous erup- 
tions and dermatographia may accompany the above process. 
Trophic changes, with resulting atrophy, fragility of bones, 
enlagement of the hands, and tendency to the development of 
whitlow and abscesses, are also to be noted. 

The course is progressive, and results fatally when bulbar 
crises set in. In the diagnosis, the idiopathic muscular dys- 
trophies, hysteria and multiple neuritis are to be excluded. 
The distinct features of syringomyelia are its gradual de- 
velopment and insidious onset, and the dissociation of touch 
and pain in conjunction with motor, trophic and vasomotor 
disturbances. 



DISEASES OF THE NERVOUS SYSTEM. 523 

MULTIPLE CEREBRO-SPINAL SCLEROSIS. 

Multiple or disseminated sclerosis, as the name implies, is 
a degenerative process affecting the brain and cord as an ir- 
regularly seattered sclerotic process. The islets of sclerosis 
are found principally in the centrum ovale, cms, pons and 
medulla in the biain, and in the cord they are irregularly 
scattered, as a rule attacking the white matter more promi- 
nently than the gray. It is most common between the ages 
of twenty and thirty, but it may occur in children or even be 
congenital. 

The cause of multiple sclerosis is probably to be found in 
an infection, but, judging from the numerous and often mixed 
infections noted, it seems unlikely that we have to deal with 
a specific organism. — (Church.) 

Symptomatology. — Owing to the widely-distributed lesions 
of multiple sclerosis a variety of disturbances are encountered 
in the nervous system. The characteristic and most promi- 
nent features of the disease are : 

{a). Motor. — A coarse, jerky incoordination, especially in 
the arms, observed on attempts at voluntary movements. 
This intention tremor is associated with progressively increas- 
ing loss of power. The gait is spastic and is associated with 
deranged equilibrium (cerebello-spasmodic gait). 

(b.) Sensory disturbances are practically confined to the eye. 
Nystagmus is a frequent symptom, and optic neuritis and 
atrophy may develop. 

(c.) Cerebral Disturbances. — The speech defect, known as 
u scanning speech, " in which there is an undue separation 
and accentuation of the syllables of words, and a state of in- 
difference, loss of memory and dejection, are the prominent 
cerebral features of the disease. A predisposition to hysteria 
seems to exist, and it is not uncommon to find livsterical 
manifestations complicating multiple sclerosis. 

(d.) The deep reflexes are exaggerated, as a rule, but there 
may be a loss of knee-jerk, and paralysis of cranial nerves in 
some cases. 



524 DISEASES OF CHILDREN. 

The course of multiple sclerosis is quite irregular. It may 
begin gradually and increase in a progressive manner, or it 
may begin abruptly as an apoplectiform attack, or with vertigo 
or visual disturbances. Remissions are not infrequent, and 
may lead to a belief that the disease has been checked ; but 
complete recovery must be very rare, although Church con- 
siders it possible. 

Diagnosis. — Multiple sclerosis is to be differentiated from 
infantile cerebral palsy, hysteria and family ataxia. In in- 
fantile cerebral palsy the history of traumatism during birth 
and the early appearance of diplegia, followed by mental re- 
tardation, rigidity and athetosis, will serve as a distinguish- 
ing feature. In hysteria the mental stigmata, the absence of 
nystagmus, and the presence of sensory disturbances and 
muscular rigidity, are of great significance, although both 
diseases may be associated in the same patient. In family 
ataxia there is inco-ordination and spasmodic muscular 
action ; the knee-jerks are abolished, the muscles are flaccid, 
and the eyes are seldom affected, except by a slight degree of 
nystagmus, with lateral rotation of the eyes. 

The treatment of these cases is very unsatisfactory. Ac- 
cording to Arndt, Arsenicum is of especial value. Tarantula 
has also been recommended. Bartlett refers to the salts of 
gold, lead and mercury. 

MULTIPLE NEURITIS. 

Inflammation of several nerves occurring at the same time 
or in quick succession occurs mainly from diphtheria during 
childhood. Malaria, typhoid fever, scarlet fever, measles, in- 
fluenza and acute rheumatism are responsible for some cases, 
but to a much less degree than the first mentioned infection. 
In marantic conditions and as a result of the cachexia of 
tuberculosis it may be encountered. Toxic cases, notably 
those seen in adults resulting from alcohol, arsenic and mer- 
cury are rare in childhood. There is a class of idiopathic 
cases that is quite puzzling. To this belong the rheumatic 



DISEASES OF THE NERVOUS SYSTEM. 525 

cases following exposure to cold or resulting from over-ex- 
ertion and those coming on suddenly with febrile symptoms, 
in the midst of apparently perfect health. Clinically they 
resemble acute poliomyelitis closely, especially when occur- 
ring in epidemics. 

The lesions are a degenerative process in the axis-cylin- 
ders, not, however, affecting the nerve trunk uniformly and 
completely. This is associated with hyperaemia of the peri- 
and endoneurium. In some of the severer cases of diphter- 
itic paralysis degenerative lesions have been demonstrated in 
the cord and even in the brain in association with the neu- 
ritis. 

Symptomatology. — The clinical course of diphtheritic 
paralysis has been described under Diphtheria. In non-diph- 
theritic cases there is first noticed a general weakness of the 
muscles, together with pain and tenderness along the affected 
nerves. Tingling and formication are also frequently com- 
plained of. The paralysis which results is usually of wide 
distribution, producing foot-drop and wrist-drop, inability to 
walk, and spinal curvature. Partial anaesthesia likewise de- 
velops, and considerable atrophy of the paralyzed muscles 
takes place. The knee-jerk is abolished, and if power of 
locomotion is not entirely lost the child shows marked ataxia 
in walking and standing. In the course of a few weeks im- 
provement sets in, and after a time complete recovery is the rule, 
although permanent loss of function may persist. Permanent 
disability is rare in children and the prognosis is good, as the 
etiologic factors responsible for the unfavorable outcome in 
adults — such as alcohol — do not enter here. A fatal termina- 
tion may take place in diphtheritic paralysis, or in other 
cases of rapid onset and wide distribution, in which the res- 
piratory and cardiac innervation becomes involved. 

Diagnosis. — The gradual onset, usually developing during 
the period of convalescence from an infectious disease or af- 
ter exposure to damp and cold (rheumatic cases), the sym- 
metrical distribution, and the accompanying sensory disturb- 



526 DISEASES OF CHILDREN. 

ances, will serve to differentiate multiple neuritis from polio- 
myelitis anterior, as well as from the various ataxias. Its 
tendency to progressive improvement and recovery is another 
feature of diagnostic importance. The presence of pain is an 
important symptom, especially tenderness along the nerve 
trunks. In children it is often difficult to estimate the de- 
gree of pain, but, as Koplik says, the children resent being 
handled, and they cry most of the time and are restless at 
night, consequently it is safe to infer that they have pain. 
It is true, there may be pain in the early stages of acute 
poliomyelitis, but the general paralysis clears up more quickly 
and atrophy in a single limb or rarely in a portion of two 
limbs rapidly sets in. The electrical reactions are more typ- 
ical and constant than in neuritis. 

Treatment. — The child should be kept in bed and put on 
a plain, highly nutritious diet. Mild galvanization of the 
affected nerves and, as atrophy sets in, massage of the mus- 
cles are of great benefit. To overcome deformity in the ex- 
tremities it may be necessary to resort to mechanical devices. 

Aconite. — Recent cases following exposure. Tingling and 
formication in the affected parts is its chief indication. This 
and Rhus tox. are the chief remedies in idiopathic neuritis. 

Arse?t. — Malarial or cachetic cases; burning pains; gen- 
eral prostration. Marantic origin ; cachexia. 

Arge?itum nitr. — Ataxic symptoms. 

Causticum is a most useful remedy for localized paralyses 
due to neuritis, or for the later changes of multiple neuritis. 

Gelse??iiu?n is useful in the early period of infectious cases, 
notably in diphtheritic paralysis. 

Rhus tox. is of great value in rheumatic cases. Traumatic 
cases call for Arnica and Hypericum, especially the latter. 

SYMPTOMATIC AFFECTIONS: NEURALGIA. 

Neuralgic pains may be observed in malnutrition and 
anaemia, particularly in chlorosis, or they may indicate a 
malarial infection. Hysteria is another prominent factor in 



DISEASES OF THE NERVOUS SYSTEM. 527 

the etiology of various painful affections of childhood in 
which structural changes cannot be demonstrated, but on 
the whole neuralgia is uncommon before the period of pu- 
berty. 

Gastralgia is a form of neuralgia which is usually the re- 
sult of indigestion. It is discussed under the diseases of the 
stomach. Local irritations, especially carious teeth, are com- 
mon causes for neuralgia. Referred pains have their special 
significance, e. g., pain in the knee in hip-joint disease ; ab- 
dominal pain in pleurisy ; the various forms of headache re- 
sulting from eye-strain, nose and ear disease, etc. 

Before a diagnosis of neuralgia can be positively made, it 
is essential to exclude all inflammatory conditions or sources 
of local irritation which might possibly cause the pains com- 
plained of. This is especially necessary in children, as seri- 
ous organic disease may be overlooked by neglect of this pre- 
caution. 

The treatment is mainly constitutional. A sufficiency of 
out-of-door exercise should be combined with a diet consist- 
ing especially of fats, milk, and vegetables. If anaemia is a 
pronounced feature, this should be corrected (see " An&mia") 
The most useful remedies in neuralgia are Aconite, Arseni- 
cum, Belladonna, Chamomilla, China, Colocynthis, Gelsemi- 
num, Rhus tox. and Spigelia. The characteristics of these 
remedies must be taken into consideration in prescribing for 
a neuralgic affection, noting the locality, the character of the 
pain and the aggravation and amelioration. In chronic cases, 
constitutional treatment gives the best results. 

HEADACHE. 

A variety of conditions — notably anaemia, lithaemia, eye- 
strain, neurasthenia, hysteria and gastric derangements — 
give rise to headache as a symptom meriting special atten- 
tion. In inflammatory and organic brain affections it is a 
prominent symptom, and in the infectious fevers and in 
uraemia it is quite constantly present. 



528 DISEASES OF CHILDREN. 

Migraine is an essential headache, coming paroxysmally 
and resulting from nervous discharges in the cortical sensory 
centres. The exciting causes may be any of the disturbances 
capable of producing headache, such as mental or physical 
fatigue, eye-strain, acute indigestion, etc. The condition 
itself is usually hereditary, and is one of the manifestations 
of a neuropathic constitution, being, so to speak, a sensory 
epilepsy. 

The symptoms of migraine in childhood are the same as 
those observed in adults, with the exception that they are not 
quite so severe and usually of less frequent occurrence. Scin- 
tillating scotomata are often observed, being described as 
fiery flashes or figures before the eyes. The pain may be 
confined to one side of the head, and is accompanied by nau- 
sea and vomiting, the latter giving relief, as a rule, although 
indigestion has nothing to do with these attacks excepting 
that it may act as an exciting cause. Other disturbances — 
e. g., amblyopia; hemianopsia; aphasia; numbness and ting- 
ling in various parts of the body, followed by anaesthesia, and 
possibly paralysis — may be observed during an attack. 

The diagnosis of migraine is based upon the paroxysmal 
nature of the attacks, the presence of nausea and vomiting 
without gastric derangement, and the accompanying sensory 
disturbances. Symptomatic headaches are recognized by their 
transitory nature and the presence of one of the causes enu- 
merated above as causing the same. It is important both 
from the standpoint of prognosis and treatment to exclude 
intracranial disease in these cases by carefully searching 
for evidences of the same, and observing the patient over a 
sufficient length of time to determine the true nature of the 
case. 

Treatment. — Children subject to migraine should be care- 
fully dieted, especially avoiding sugar and starch, as these pa- 
tients are usually lithaemic. Errors of refraction must receive 
prompt attention. One of the following remedies will usu- 
ally be indicated during the paroxysm 



DISEASES OF THE NERVOUS SYSTEM. 529 

Arg. nitr. — Deep-seated pains in the temples of a boring or 
pressing character, relieved by pressure. Dimness of vision 
with vertigo, tendency to fall to the side. At its height there 
are trembling of the whole body and intense nausea. Attack 
preceded by chilliness, indisposition and loss of appetite. 

Bell. — Congestive headache ; throbbing of the carotids ; 
throbbing pains in the temples ; face flushed. Often right- 
sided. The pain is worse lying down, and is temporarily re- 
lieved from sitting up. 

Cham. — Beginning with flickering and fiery zigzags before 
the eyes. Great irritability of temper. 

Glon. — Violent pulsations in brain from below upward ; 
there is high arterial tension ; vertigo ; ringing in the ears 
and palpitation of the heart, each beat seeming to increase the 
pain in the head. Brought on by exposure to the sun. 

Ig?iatia. — Hysterical headache ; clavus hystericus ; from 
emotional excitement or over-pressure at school. Highly 
nervous temperaments. 

Iris. — The attack begins with dimness of vision and termi- 
nates with the vomiting of a yellowish, bitter, sour-smelling 
fluid. Usually right-sided. 

Pulsatilla. — Left-sided attacks, with anorexia, belching and 
vomiting. Anaemia in mild, yielding subjects. 

Sanguinaria. -Pain beginning in occiput and spreading 
over the top of the head, settling over the right eye. Great 
sensitiveness to light ; flushes of heat and alternate chilliness. 
The attack ends in vomiting. 

Spigelia. — Neuralgic pains over the left eye Chlorosis. 



CHAPTER XVII. 

DISEASES OF THE EAR, NOSE AND THROAT. 
OTITIS. 

Inflammation of the middle ear is of common occurrence 
during infancy and childhood, although it is a condition that 
is frequently not suspected unless an ear discharge appears. 
Being often followed by most serious sequelae, which may 
either result in the death of the patient or leave him perma- 
nently deaf for the remainder of his life, it is of the greatest 
importance that its advent should be anticipated ; that it be 
recognized early and the proper treatment instituted during the 
course of the attack. Every case of otitis, however, does not 
present so serious a prognosis. As will be seen from the de- 
scription of the course of the different varieties, there is a 
mild, catarrhal form complicating rhino-pharyngitis or appar- 
ently occurring primarily and also a serious suppurative vari- 
ety occurring as a complication of one of the infectious fevers, 
notably scarlatina. 

The external auditory canal is directed more forward in the 
infant than in the adult, for which reason it is at times neces- 
sary to draw the lobe of the ear downward and forward in 
order to insert the speculum instead of drawing the aurical 
upward and backward, as in adults. Often the speculum is 
best inserted when traction is made directly backward on the 
aurical, and I cannot say that, as a rule, I find the direction 
of the canal forward, as mentioned in most text-books. 

The Eustachian tube is wider, shorter and more horizon- 
tally placed than in the adult, and this anatomical feature, in 
conjunction with the prone position so constantly assumed by 
the child, offers the explanation why extension of an infec- 
tion of the nose and throat travels so readily through the tym- 



DISEASES OF THE EAR, NOSE AND THROAT. 531 

panum. The tympanic orifice is larger than the pharyngeal. 
Inflation of the middle ear is more easily accomplished than 
in adults. 

The membrana tympani, or drum head, is almost horizon- 
tally placed, at first gradually assuming the perpendicular as 
the ear develops. It is thicker than in the adult and does 
not rupture so readily spontaneously. 

The tympanic cavity is bounded superiorly by a thin plate 
of bone upon which the middle lobe of the brain rests. In 
the infant a suture, the petroso-squamosal, is found, allowing 
a vascular communication between the middle ear and the 
dura mater. For this reason meningeal irritation is so com- 
monly observed in conjunction with otitis media. The close 
proximity of the inferior wall to the jugular fossa accounts 
for the liability of phlebitis and thrombosis of the jugular 
vein to occur as complications. 

The upper portion of the tympanic cavity containing the 
malleus and part of the incus is known as the attic. It com- 
municates with the mastoid antrum, and for this reason an ac- 
cumulation of pus in the tympanum reaching to or confined 
to this point is usually followed by infection of the mastoid 
process. On account of the undeveloped state of the mastoid, 
however, involvement of the petrous bone and of the brain is 
more common than mastoiditis. 

The mucous membrane lining the tympanum is quite thin 
and vascular, presenting a reddish and swollen appearance in 
young infants. 

The mastoid process is but a small, undeveloped tuberosity 
at birth and contains, as a rule, only one cell, the antrum. It 
gradually develops by extending downwards and at the age of 
five years reaches the adult type. The upper wall of the 
antrum is in close proximity to the dura mater, being sepa- 
rated therefrom by only a thin lamina of bone. 

The facial nerve passes along the upper portion of the 
tympanic cavity and downward through the mastoid cells. 
For this reason it frequently becomes affected in middle ear 
and mastoid disease. 



532 DISEASES OF CHILDREN. 

Earache is the most prominent symptom of otitis, but it is 
possible for an inflammation of the middle ear to exist with- 
out any definite pain. This sometimes occurs in marantic 
infants, in whom an ear discharge may be the first sign of the 
trouble. Again, the pain may be vague and not definitely 
localized or be masked by cerebral irritation, but in these 
cases pressure at the tragus will usually elicit tenderness. 

Tenderness and redness (inflammatory blush) over the 
mastoid indicates involvement of the mastoid cells and is an 
unfavorable symptom. 

Discharge. — In the acute forms of otitis media that lead to 
perforation of the membrana tympani the discharge at first is 
serous as a rule, becoming muco-purulent later on. In the 
severe form, namely, that complicating scarlet fever, it is 
usually purulent from the beginning ; the ordinary catarrhal 
variety, however, may assume a purulent character if its course 
becomes protracted. 

Tuberculosis. — In the tuberculous variety of otitis the 
mucous membrane of the tympanic cavity is pale and the 
discharge is watery or a thin pus, in which the tubercle 
bacillus may be demonstrated. 

Influenza. — A large number of cases of otitis are due to 
infection with the influenza bacillus. In these cases the dis- 
charge at first is sero-sanguinolent, later becoming stick}-. 
There is always more or less blood, on account of the great 
congestion of the mucous membrane of the tympanum and 
of the drum head. 

ACUTE CATARRHAL AND ACUTE PURULENT OTITIS MEDIA. 

The two varieties will be considered under the same head- 
ing, as it is impossible to draw a sharp line of distinction be- 
tween them. Frequently what in the beginning seems to be 
a catarrhal otitis eventually becomes a purulent one and 
again, the early symptoms of both varieties are almost identi- 
cal. This much, however, may be said, the catarrhal variety 
is by far the commoner in infants, while in older children the 



DISEASES OF THE EAR, NOSE AND THROAT. 533 

purulent variety predominates. The eNplanation of this 
lies in the fact that catarrhal otitis usually develops second- 
arily to an acute naso-pharyngitis, while the purulent variety 
develops in the course of one of the infectious diseases, nota- 
bly, scarlet fever and measles, and less frequently in typhoid 
fever, pneumonia and diphtheria. Influenza is a common 
cause of the more severe catarrhal cases. The micro-organ- 
isms most commonly found in the discharge are the pneumo- 
coccus and the streptococcus ; the latter is responsible for the 
damage done to the middle ear and adjacent structures in 
scarlatinal otitis and the other grave symptoms of suppurative 
otitis. As a predisposing cause adenoid vegetations stand 
most prominently. 

Symptomatology. — In infants otitis is usually preceded by 
a naso-pharyngitis ; as the ear becomes involved there is an 
increase of fever and earache sets in. Although the child fre- 
quently gives evidence of the seat of the pain by putting the 
hand to the side of the head and by crying when the affected 
ear is touched, still there are a great many cases in which ear- 
ache is not suspected until the membrana tympani has rup- 
tured and a discharge makes its appearance. This is espe- 
cially the case when otitis complicates an acute illness, such 
as pneumonia for example. In these cases there will be a 
rise of temperature that cannot be accounted for and the 
child will cry incessantly for no known reason. In the 
course of a day or two the appearance of the ear discharge 
clears up the mystery. Sudden exacerbation of fever in any 
acute illness not accounted for by other complications should 
always lead to an examination of the ears. 

The crying of earache is characteristic. When we are con- 
fronted with an infant that is crying continuously in spite of 
ever) effort that may be made to make it comfortable, and, if 
other causes can be excluded, there is every reason to 
suspect earache. 

In older children the disease is ushered in with excruciat- 
ing pain and high elevation of temperature. Pain begins in 



534 DISEASES OF CHILDREN. 

the ear, but radiates practically over the entire side of the 
head. As a rule, it is promptly relieved when perforation 
takes place. 

Often the symptoms closely resemble meningitis, the dis- 
ease is ushered in by convulsions and vomiting, and marked 
cerebral irritation is present on account of the close connec- 
tion between the middle ear and the dura mater. These 
symptoms, however, disappear as soon as the middle ear is 
evacuated. 

Many subjective symptoms are complained of, but the most 
important ones of the disease are those above referred to. 

Early in the disease the drum head in the region of Shrap- 
nell's membrane is congested. There is also hyperaemia ex- 
tending along the posterior border of the handle of the mal- 
leus ; the drum-head loses its lustre and assumes a deep pink 
color varying with the intensity of the inflammation. The 
external auditory canal also becomes deeply congested. 

At first the drum head is somewhat depressed, but as the 
exudate fills the tympanic cavity it bulges, especially in 
its posterior half. When perforation occurs it most frequently 
takes place in the lower anterior or posterior quadrant of the 
membrane. Spontaneous perforation is less apt to drain the 
tympanum as thoroughly as an artificial puncture, nor does it 
heal as well. 

When the pain continues after perforation, we should suspect 
involvement of the periosteal layer, or of the mastoid cells. 

The complications .of otitis media are mastoiditis ; facial 
paralysis; meningitis; cerebral abscess ; septicaemia; throm- 
bosis of the lateral or other sinuses ; caries of the sinuses ; 
facial erysipelas and eczema aurium. As has been stated 
above, affections of the petrous bone and of the brain are 
commoner complications than mastoid disease in children. 
When the hearing is lost as a consequence of otitis, in the 
very young, deaf-mutism supervenes. 

Prognosis. — There are two factors influencing the prog- 
nosis of otitis in children. In the first place the constitution 



DISEASES OF THE EAR, NOSE AND THROAT. 535 

and the state of health at the time the disease is contracted 
are important factors. Secondly, the nature of the causative 
infection is important ; those complicating a simple rhino- 
pharyngitis or influenza are not as grave as those complicat- 
ing scarlet fever (streptococcic) or those due to the pneumo- 
coccus or to the diphtheria bacillus. Again, the develop- 
ment of a complication augurs an unfavorable prognosis, and 
practically makes it a surgical condition. The prognosis is 
always more favorable when early incision of the drum-head 
has been made and free drainage established. 

Diagnosis. — Earache should always be suspected when 
an infant cries continuously or when the fever suddenly rises 
during the course of an acute illness without assignable cause. 
The throat must be examined for evidences of pharyngitis 
and when enlarged tonsils and adenoids are found the possi- 
bility of earache should never be lost sight of. Inspection of 
the ear drum will give positive evidence of the disease. 

Treatment. — Absolute rest in bed should be enforced and 
much relief of suffering may be obtained by instilling hot 
water into the external auditory meatus, or, better, by the in- 
stillation of a 10 per cent, solution of Carbolic acid crystals in 
glycerin in the hope of aborting the attack by osmotic action 
through the membrana tympani. Fill the external canal every 
two to three hours with a 10 per cent, solution of crystals of 
acid Carbol. in glycerin. This is not only useful in relieving 
the pain, but will at times abort the attack by osmotic action 
through the membrana tympani, and in any case it will ren- 
der the canal aseptic in anticipation of perforation, natural or 
artificial (C. M. Thomas). 

The most important remedies are Aconite, Belladonna and 
Pulsatilla. Even the old-school places great confidence in 
these remedies. Thus, Bacon {Manual of Otology) says: 
"Aconite in drop doses is a most valuable remedy when there 
is fever and especially in cases due to cold. Tincture of 
Pulsatilla, likewise given in drop doses, is indicated also in 
cases in which there is a profuse discharge from the nares or 



536 DISEASES OF CHILDREN. 

nasopharynx, and may be administered alternately with 
Aconite." The nose and throat should also teceive attention. 
When these measures fail to give relief, and if the fever 
and concomitant symptoms persist, the next indication for 
treatment is to freely incise the drum-head. Thomas (Hahne- 
mannian Monthly, Oct., 1901) lays down the following rule : 
the acuter the attack and the more severe the suffering and 
prostration, the earlier should this operation be done. 

A successful paracentesis is a free incision of the membrane 
and not merely a puncture. The technique is as follows : 
the patient having been anaesthetized and the external audi- 
tory canal thoroughly cleansed with a hot 1-5000 bichloride 
of mercury solution, the drum-head is inspected with the aid 
of a speculum and head-mirror in order to determine the site 

of bulging if this be demonstrable. 
The incision is made with a narrow 
bistoury or tenotome. Ordinarily 
the line of incision extends from 
just behind the stapes to the lower 
fig. 51.— line of incision border of the drum-head, closely 

THROUGH DRUM-HEAD , - , £ , 

„ N hugging the bony structure of the 

(after bacon). fet > o J 

canal (Fig. 51). In grave cases, with 
bulging of the drum-head in its posterior and upper quadrant, 
together with indications of mastoiditis, the incision should 
be carried well up the posterior fold and into the attic. At the 
same time the knife should be brought out along the upper 
posterior wall of the external auditory canal to relieve all 
tension. The canal is then lightly packed with sterile gauze 
and after the acute symptoms have subsided irrigation with 
1-5000 bichloride solution may be practiced several times 
daily. If the discharge persists Thomas recommends the in- 
stillation of a saturated solution of Boric acid in alcohol, fol- 
lowed by: Zinc, sulph., Acid carbol., aa, grs. 5; aqua distil.; 
alcohol, aa oz. y 2 ; eight to ten drops instilled after cleansing, 
three times daily. Inflation, cautiously employed, when the 
perforation is large, helps to remove the secretion from the 
tympanum. 




DISEASES OF THE EAR, NOSE AND THROAT. 537 

Remedies. — In the acute stage, Aconite and Pulsatilla are 
most commonly indicated (see above). Bellado7tna is the 
remedy when cerebral symptoms are prominent. Capsicum 
comes highly recommended for the early stages of mastoid 
involvement. 

During the period of discharge, Pulsatilla and Calcarea 
iodid. are most useful. Hydrastis is particularly indicated in 
influenzal cases, where the discharge is sticky and tenacious. 
When the discharge excoriates we should think of Mercurius 
and in involvement of the bone Silica is the most useful 
remedy. 

As the discharge decreases the instillations should be made 
less frequently and finally daily dusting of the canal with 
Boric acid should be substituted. After cessation of the dis- 
charge and closure of the perforation the restoration of hear- 
ing will be greatly hastened by cautious inflation with the 
Politzer bag or catheter, every one to'two days (Thomas). 

ACUTE TONSILLITIS. 

Acute inflammation of the tonsil may be either superficial, 
or catarrhal ; folliculous, or cyptic ; and parenchymatous. 
Anatomically the tonsils consist of an aggregation of lym- 
phoid tissue embedded in connective tissue and covered by a 
mucous membrane from whose surface numerous mucous 
glands dip into its parenchyma. These glands form the so- 
called crypts, or follicles, and they play an important role in 
the diseases of the tonsil. 

Clinically the tonsil is most important as the port of en- 
trance of the infective agent of many of the infectious dis- 
eases. Diphtheria and scarlet fever notably attack the 
tonsils, and rheumatic fever is now looked upon as fre- 
quently beginning as a tonsillar infection. Indeed, a special 
variety of tonsillitis designated " rheumatic tonsillitis " is 
described by some writers, but such a condition should be, 
strictly speaking, looked upon as an attack of rheumatic in- 
fection in which tonsillar symptoms predominate, for in these 

35 



538 DISEASES OF CHILDREN. 

cases, especially in children, a carefnl examination of the case 
often reveals the presence of endocarditis and tenderness in 
the joints. 

Acute Superficial Tonsillitis. — As the name implies, acute 
superficial tonsillitis involves only the mucous membrane 
covering the tonsil, but as a rule deeper structures are more 
or less involved. The process may also spread to contiguous 
structures, and it either undergoes prompt resolution or in 
the case of secondary infection is followed by superficial 
necrosis of the epithelium, or suppuration of the connective 
tissue takes place, resulting in peritonsillar abscess. 

It is a common accompaniment of many of the infectious 
diseases, notably measles and scarlet fever. In primary cases 
the usual etiological factor is " taking cold," and by many it 
is believed that the " rheumatic diathesis " offers especial 
predisposition to these attacks. 

Symptomatology. — In primary cases there is malaise and 
slight chilliness, together with dryness of the throat and more 
or less pain on swallowing. The tonsils appear bright red, 
swollen, and their surface presents a somewhat cedematous 
appearance. It is seldom that the process ends here, however, 
the crypts usually becoming occluded and filled with fibrin, 
leucocytes and epithelial debris, which constitutes acute fol- 
liculous tonsillitis. 

Associated symptoms are fever ; headache and malaise ; 
stiffness of the neck, even torticollis and earache. 

ACUTE FOLLICULOUS TONSILLITIS. 

Acute folliculous, or cryptic tonsillitis, is an acute infection 
of the tonsils. The geims usually found are the strepto- 
coccus, staphylococcus, and pneumococcus. In many cases 
there is associated superficial necrosis of the mucous mem- 
brane covering the tonsils, together with an exudation of 
fibrin and the formation of irregular patches of pseudo-mem- 
brane. This condition is a frequent complication of scarlet 
fever, although it may occur independently. It is known as 
u pseudo-diphtheria." 



DISEASES OF THE EAR, NOSE AND THROAT. 539 

Symptomatology. — The attack begins with malaise and 
creepy sensations, usually along the spine, followed by fever 
and aching throughout the body. There is dryness of the 
throat and some pain on swallowing, but frequently the child 
does not refer to its throat until the tonsils are greatly swollen, 
and one is often led to look upon the condition as influenza 
or beginning typhoid fever unless the routine examination of 
the throat is practiced. 

Fever persists for about three days, together with an incre- 
ment in the severity of the symptoms, ranging between ico° 
F. to 105° F. By this time the inflammation of the tonsils 
has reached its climax and they present a characteristic ap- 
pearance. They are deeply congested, uniformly swollen and 
their surface is studded with yellowish-white, punctate spots 
appearing at the mouths of the crypts. When the exudation 
is abundant it spreads Over the surface of the tonsils and may 
give rise to the appearance of a membrane. This is, how- 
ever, readily wiped off. Again, necrosis of the epithelium 
around the mouths of the crypts frequently takes place, the 
spots assuming an irregular outline, like a diphtheritic mem- 
brane, and these spots may coalesce ; but the deposit is only 
superficial and is readily wiped off, distinguishing it from 
diphtheria. 

The lymphatic glands of the neck may become enlarged 
and tender, but never to the extent found in diphtheria. 

Associated symptoms are painful deglutition — in fact pain 
at the height of the disease is one of its most characteristic 
symptoms ; lancinating pains extending into the ears ; head- 
ache and prostration. 

The tongue is coated and slimy ; the breath is offensive, 
but nothing like in diphtheria, and there is anorexia and con- 
stipation. 

The fever subsides on about the third day ; the tonsillar 
swelling abates at the same time, and convalescence is estab- 
lished in the course of a few days. 

Diagnosis. — The most important condition from which 



540 DISEASES OF CHILDREN. 

folliculous tonsillitis is to be distinguished is diphtheria. In a 
typical case this is comparatively easy, but in the class of cases 
described as pseudo-diphtheria many difficulties are encoun- 
tered. High fever, occurring suddenly in older children, is 
perhaps most frequently due to tonsillitis. 

The characteristic points to be remembered in the diag- 
nosis of folliculous tonsillitis are : The punctate spots of soft, 
unorganized exudation confined to the tonsillar crypts ; the 
uniform inflammation and swelling of the tonsils ; the high 
fever and pain and the absence of profound toxaemia ; and, 
lastly, the absence of marked enlargement of the lymphatics 
of the neck. In all doubtful cases, however, a bacteriological 
examination of the exudate should be made, for in rare in- 
stances the diphtheria bacillus sets up a tonsillitis identical 
in appearance with the ordinary folliculous variety. 

Treatment. — If there be fever the child should be put to 
bed and isolation of the patient enforced. When there is 
much pain and swelling of the tonsils an ice collar will give 
decided relief. The throat may be sprayed several times daily 
with a mild antiseptic, such as Asepticon (Boericke & Tafel) 
diluted with warm water, and when there is considerable ex- 
udate and offensive breath the Permanganate of Potash, i to 
1,000 solution, is preferable. 

The most important remedies are : Belladonna, Mercurius 
iod. rubr., Apis and Ignatia. 

Belladoiina is indicated in the early stage when there is 
dryness and redness of the throat with pain on swallowing; 
throbbing headache ; photophobia ; high fever and flushed 
face. It is more frequently indicated in tonsillitis in children 
than in adults. 

Apis is indicated when ©edematous swelling of the mucous 
membrane is the leading feature in the case. There are sharp, 
sticking pains on swallowing. 

Ignatia is a valuable remedy in folliculous tonsillitis when 
there are sharp, lancinating pains extending into the ears. 

Mercurius iod. rubr. is the most useful remedy in the fully 
developed stage, especially when exudation is abundant. 



DISEASES OF THE EAR, NOSE AND THROAT. 541 

ULCEROMEMBRANOUS TONSILLITIS. 

This is a condition presenting a marked outward resem- 
blance to diphtheria, but on close study it will be seen that 
the resemblance is merely superficial. In ulcero-membranous 
tonsillitis the tonsil becomes covered with a dirty-yellowish 
exudate ; this is often confined to a single tonsil. When the 
exudate is wiped away, especially when done roughly, a bleed- 
ing surface may remain. The lymphatics at the angle of the 
jaw on the affected side are swollen. Thus far there is a 
strong resemblance to diphtheria, even to offensive breath, 
but constitutional symptoms are slight or wanting and a bac- 
teriological examination reveals instead of the Klebs-Loeffler 
bacillus the fusiform bacillus discovered by Vincent and sup- 
posed to be the etiological factor. Pseudo-diphtheria is also 
to be differentiated (see Diphtheria;. 

Ulcero-membranous tonsillitis is at times associated with 
ulcerative stomatitis and is looked upon as being an analogous 
condition. 

The treatment is the same as for other forms of tonsillitis. 
Locally, Hydrogen dioxid, preferably as a spray, is the most 
useful disinfectant. The red Iodide of Merairy is well indi- 
cated as an internal remedy. For fuller symptomatology see 
"Tonsillitis." 

Merc. iod. rnbr. — This is the most useful remedy in cases 
resembling diphtheria where there is superficial ulceration of 
the tonsils ; fibrinous exudation and enlargement of the cerv- 
ical lymphatics. 

ACUTE PARENCHYMATOUS TONSILLITIS ; PERITONSILLAR 

ABSCESS. 

Acute parenchymatous tonsillitis, commonly called 
u quinsy," results from an infection of the tonsil from with- 
out, either following superficial ulceration or associated with 
a membranous or inflammatory process of the tonsil and 
surrounding structure ; it may also be secondary to some 



542 DISEASES OF CHILDREN. 

other form of tonsillitis and to the infectious diseases ; and it 
may be associated with systemic septic processes (Kyle). 

Suppuration as a rule sets in, taking place in the periton- 
sillar connective tissue and terminating in the formation of 
an abscess which may rupture into the pharynx either an- 
teriorly or posteriorly, following the line of least resistance. 
It is a disease common in later childhood and in adolescents. 

Symptomatology. — The onset is similar to that of other 
forms of tonsillitis, with the exception that the inflammation 
is one-sided and attended with more pain and swelling. The 
pain at first is lancinating ; later it becomes throbbing in 
character. There is a constant desire to swallow, which adds 
greatly to the discomfort of the patient. Fever and malaise 
are usually not so marked as in folliculous tonsillitis. 

On inspection, the throat presents a swollen, cedematous 
appearance and a tumefaction arising from the tonsillar re- 
gion is seen projecting toward the median line. The tonsils 
and pharynx are covered with a grayish, viscid mucus which 
gives the appearance of a thin pseudo-membrane being pres- 
ent, but by spraying the throat it can be completely removed. 
The tonsil itself is not the seat of the chief swelling, but it is 
simply carried into the median line by the surrounding tume- 
fied structures. The opposite side may become affected later 
on, but the disease is rarely bilateral. Inspection is difficult 
on account of the stiffness of the jaw that is associated. Fluc- 
tuation may be elicited, but it is not always easy to deter- 
mine on account of the boggy, cedematous condition of the 
tissues. 

The duration is from a few days to a week or longer. 
Resolution may set in, or spontaneous evacuation take place 
after four or five days with prompt relief of the symptoms. 

Treatment. — If suppuration cannot be aborted by the use 
of the ice-bag and the indicated remedy, the abscess should 
be evacuated as soon as pus is suspected and an antiseptic 
gargle freely used. The incision is made with a sharp 
pointed bistoury whose cutting edge has been wrapped in 



DISEASES OF THE EAR, NOSE AND THROAT. 543 

cotton, exposing only the point for a distance of about a 
quarter of an inch. The point is inserted to its full length 
into the substance of the half arch just above the tonsil and 
a quarter of an inch from its free border, and the tissue cut 
through and across, toward the median line. Peritonsilar 
abscess can often be most satisfactorily evacuated by passing 
a bent probe outward and upward posteriorly to the anterior 
half and into the supra tonsillar fossa (Thomas). The pa- 
tient should then gargle with a warm 2 per cent. Boric acid 
solution, or preferably diluted Hydrogen dioxid so long as 
pus is present. 

Remedies. — Belladonna in the early stage; later, as soon 
as pus begins to form, Mercurius vivus ; and Hepar sulph. 
to hasten resolution, are the remedies that will be needed in 
the majority of cases. 

Apis may become indicated from a predominance of oedema. 
In fact, oedema of the glottis may supervene, and for this con- 
dition Apis is looked upon as invaluable. 

Capsicum. — Serous infiltration of the faucial tisssues ; 
boggy not ©edematous, in appearance ; left side worse ; pain 
burning, stinging. When tongue is heavily coated white, 
uvula cedematous, especially with a dusky infiltration of the 
left pillars and some swelling of the lymphatic glands, Caps., 
in the 3X or 6x, will usually relieve inside of twenty-four 
hours (Ivins). 

Guaiacum. — Recurring attacks due to rheumatic diathesis. 

Phytolacca. — Chills and fever alternate ; prostration ; pain 
running to ears on deglutition ; affected parts dark-purple, 
almost blue ; rheumatic subjects ; uvula enlarged and cedema- 
tous. 

Silicea. — Protracted cases. Suppuration continues after 
evacuation of pus has taken place (Calc. snlph.). 

HYPERTROPHY OF THE TONSILS. 

There are two varieties of hypertrophy of the tonsils ; in 
the one the increase in structure is mainly glandular, while 



544 DISEASES OF CHILDREN. 

in the other it is interstitial. The first variety is known as 
the soft, glandular type ; the other as the hard, fibroid, or 
lobulated tonsil. An enlarged tonsil is not necessarily an 
hypertrophied one, as enlargement may result from vascular en- 
gorgement and does not necessarily indicate cell proliferation. 
Again, in children the tonsils are normally large, and because 
they extend beyond the pillars of the fauces, it does not 
necessarily follow that they are hypertrophied (Kyle). 

The cause of the various enlargements is both constitutional 
and acquired. The so-called strumous diathesis, or what is 
understood by the more modern term lymphatism, is the un- 
derlying constitution looked upon as responsible for the abnor- 
mal tendency to hyperplasia of these lymphoid structures. 
Recurring attacks of acute tonsillitis, and diphtheria and 
scarlet fever may be looked upon as the chief exciting causes. 
The condition belongs practically to the period of childhood. 

Symptomatology. — Subjective symptoms depend largely 
upon the size of the tonsils. They may be so large as to 
cause considerable interference with normal respiration by 
filling up the pharyngeal space, and under these circumstances 
the voice is also affected, acquiring a nasal twang. Many of 
the symptoms resulting from adenoid vegetations are also 
caused by enlarged tonsils. 

In the soft variety the tonsil is uniformly enlarged, while 
in the fibrous variety it is lobulated ; the crypts are abnor- 
mally large, and its consistency is hard and unyielding. 

The irregular, nodular surface of the enlarged tonsil ; its 
open crypts and eroded surface ; and its perverted function, 
render it a source of danger as an avenue for infection, beside 
its other evil effects upon the child's health. 

Treatment. — Unless the tonsils are sufficiently enlarged to 
interfere with the child's health, or to affect the voice, they 
will require no further treatment than mild local measures 
and a remedy prescribed upon a constitutional basis. When 
local symptoms are marked the remedy should be chosen on 
such indications. It is the simple, hypertrophic variety of 



DISEASES OF THE EAR, NOSE AND THROAT 



545 






enlarged tonsil without connective tissue proliferation that 
so promptly improves under appropriate treatment and under- 
goes physiological atrophy in later life. The fibroid variety, 
however, is rarely improved by treat- 
ment of any kind, and if it be large 
enough to cause symptoms it should be 
excised. 

Excision can be accomplished in 
older children under local anaesthesia 
(a 4 per cent, solution of Cocaine), 
but in the young this should not be 
attempted. The same preparations 
as for the operation for adenoids are 
made, and under good illumination 
the tonsils are cut off with the tonsil- 
lotome close to the pillars of the palate. 
When adhesions between the tonsils 
and palatine folds exist they should be 
broken up with a blunt instrument, 
such as the A His dry dissector, before 
removing the tonsil. 

Bleeding is rarely alarming, and it 
can be controlled by pressure with a 
mop dipped in a saturated solution of 
Tannic acid. Under anomalous cir- 
cumstances a haemorrhage may ensue ; 
this will require long continued pres- 
sure (with the finger or an especially 
constructed tonsillar haemostat), or it 
may become necessary to place a liga- 
ture around the stump of the tonsil. 
The after treatment is the same as for 
adenoids. 

Remedies. — Of the many remedies recommended for en- 
larged tonsils there are only a few that have given me posi- 
tive results. They are Calc. phos. and Ignatia. Baryta carb. 




in;. 52. Toxsir.LoTOMK. 



546 DISEASES OF CHILDREN. 

and jod. are usually prescribed for the class of enlargement 
that is beyond the pale of medicinal action ; consequently the 
results I have seen from them are not gratifying. Ignatia is 
of undoubted value in the early stages of simple glandular 
hypertrophy, and it especially suits those cases in which there 
is a constant recurrence of acute tonsillitis. Calc. phos. is 
the constitutional remedy best suited to the condition that 
predisposes to the overgrowth of the lymphoid structures and 
its efficacy in tonsillar hypertrophy is not to be questioned. 
If taken in time most cases will no doubt escape operation, 
but one should not be too sanguine of results in those of long 
standing. 

RETROPHARYNGEAL ABSCESS. 

The commonest variety of retro-pharyngeal abscess is the 
result of an acute infection of the lymphatic glands and ves- 
sels of the pharyngeal space ; in other words, an acute lym- 
phangitis and adenitis that has broken down in suppura- 
tion. A septic variety, occurring as a complication of scarlet 
fever and measles, is sometimes encountered, but it is much 
rarer than the idiopathic form. Chronic retro-pharyngeal ab- 
scess is due to cervical Pott's disease. This occurs in child- 
hood, while the above condition occurs almost exclusively 
during infancy. 

As the lymph-nodes of the retro-pharyngeal space are inti- 
mately connected with the lymphatics of the tonsils and 
uvula, any acute inflammatory condition of these structures 
is likely to result in involvement of the pharyngeal lym- 
phatics. This is especially the case during the period of in- 
fancy, when these glands are in a state of high physiological 
activity. Later in childhood, however, they atrophy, for 
which reason retro-pharyngeal suppuration is rare after the 
third year. 

The tumefaction may be situated in the median line, but 
more frequently it is more to the side and may even appear 
to arise from behind one of the half-arches. The glands at 



DISEASES OF THE EAR, NOSE AND THROAT. 547 

the angle of the jaw may also be implicated, in which case 
the swelling is found at or beneath the angle of the jaw and 
in front of the sternocleido-mastoid muscle. In such cases a 
spontaneous evacuation of the abscess externally may take 
place, although the majority break into the pharynx. 

Septic retro-pharyngeal abscess complicating scarlet fever 
and measles shows a tendency to burrow into the mediastinum 
or ulcerate into the carotid arteries and other important 
structures. 

Symptomatology. — The onset is insidious and usually it is 
not suspected until marked symptoms have developed, as 
there is present always a primary inflammatory condition of 
the nose or throat upon wmich it depends. In the course of 
five or six days, by which time the primary condition should 
have entirely subsided, there is still a trace of febrile move- 
ment and inspection of the throat reveals a swollen and cedem- 
atous state of the pharyngeal mucous membrane. Two or 
three days after this, evidence of suppuration becomes ap- 
parent and the swelling has attained such size as to call forth 
the symptoms characteristic of the disease. There will be 
difficulty of breathing, especially on inspiration ; crowing 
respiration, due to incoordination of the vocal cords; retrac- 
tion of the head in order to give the larynx as much free 
space as possible and distinctly nasal cry. The child breathes 
with the mouth open and holds the head so rigid that cervi- 
cal Pott's disease or torticollis may be erroneously thought to 
exist. Inspection of the throat will, however, immediately 
clear away any doubt as to the true nature of the case. The 
abscess is readily made out by carefully introducing the index 
finger into the pharynx. This must always be done with 
caution to avoid rupturing the abscess or throwing the in- 
fant into collapse by rude manipulation of the fauces. 

If allowed to rupture spontaneously the pus may be as- 
pirated into the lungs, causing instant death or setting up a 
fatal broncho-pneumonia ; it may also find its way into the 
Eustachean tubes and set up an acute otitis. In many in- 



548 DISEASES OF CHILDREN. 

stances, however, the pus is swallowed or evacuated through 
the mouth without causing any trouble. Nevertheless, prompt 
surgical interference offers the best prognosis and should be 
instituted in all cases as soon as they give indications for the 
evacuation of pus. 

Treatment. — The abscess is easily incised when it points 
to the median line or not far therefrom. Cases in which the 
swelling is well to the side require great care, as there is 
danger of wounding the carotid artery. Those pointing ex- 
ternally must be opened with great care, as deep incision must 
be made in order to thoroughly drain the abscess. Tubercu- 
lous abscesses should be opened externally whenever possible. 

The child is held firmly in the upright position and the 
throat illuminated by the head-mirror. A mouth-gag is un- 
necessary ; all that is required to expose the abscess and keep 
the mouth open is a reliable tongue depressor. The incision is 
made toward the median line with a bistoury whose cutting 
edge has been protected by wrapping it with cotton up to 
within half an inch from the point. After making the in- 
cision it is often necessary to break up septa of connective 
tissue within the abscess cavity with the tip of the index 
finger. 

The remedies indicated are Belladonna in the early stage 
and Hepar sulph. when pus begins to form. 

ACUTE RHINITIS ; PSEUDO-MEMBRANOUS RHINITIS. 

Acute rhinitis is an acute inflammation of the mucous 
membrane of the nasal cavities occurring either as a primary 
condition or secondary to one of the infectious diseases, not- 
ably measles, influenza and diphtheria ; the cause of the acute 
suppurative symptoms of rhinitis lies in infection by pyo- 
genic germs which are usually found present in the nose in 
great number. They do not, however, become active until 
the vascular engorgement of the nasal mucosa resulting from 
exposure to cold or draughts offers a favorable soil for their 
propagation, and invites them to activity. 



DISEASES OF THE EAR, NOSE AND THROAT. 549 

Pseudo-membranous rhinitis associated with faucial diph- 
theria is due to the Klebs-Laffler bacillus in its most virulent 
form, while those cases in which a diphtheritic membrane 
develops primarily in the nose, running a mild course, the 
bacillus is present in attenuated form. Such cases, however, 
may give rise to a severe faucial diphtheria, and for this rea- 
son every case of pseudo-membranous rhinitis should be iso- 
lated. This attenuated diphtheria bacillus is known as Von 
Hoffman's bacillus. According to Park (Bacteriology in 
Medicine and Surgery) only in a few cases have other bac- 
teria been found to cause the croupous exudate ; they were 
mainly the pyogenic cocci. Kyle (Diseases of the Nose and 
Throat) is of the opinion, however, that most cases of croupous 
rhinitis are simply the result of local irritation from micro- 
organisms, the streptococcus pyogenes being the most frequent 
one present in the croupous exudate. All of the cases that 
have come under my notice were diphtheritic. At times it 
seems due to some constitutional condition in which the 
individual cell resistance is below normal. It may also result 
from traumatism. 

There is no doubt that a certain amount of contagiousness 
exists in acute rhinitis. A natural predisposition is found in 
many cases ; this is particularly the case in anaemic children 
that have been reared like hot-house plants and in those of 
the so-called scrofulous diathesis. 

Symptomatology. — Following upon exposure, or "catch- 
ing cold " or in the course of an infectious disease a sense of 
fulness in the nostrils with dryness of the mucous membrane 
develops, succeeded by an acrid, watery discharge consisting 
of serum with a small amount of mucus. At this stage the 
mucous membrane appears red and swollen, and the entire 
nasal cavity may be occluded by the swollen turbinated 
bodies. 

In primary cases a slight febrile reaction sets in and there 
is headache, and lassitude. Mild cases may be aborted at 
this stage and resolution occur without any further develop- 



550 DISEASES OF CHILDREN. 

ments. In infants these attacks are spoken of as snuffles, and 
unless they are due to syphilis or are benign, profuse muco- 
purulent secretion makes its appearance, flowing freely from 
the nose and covering over the entire mucous membrane of 
the naso-pharynx. The process may extend to the frontal 
sinuses, the Eustachian tubes and middle-ear, and to the 
pharynx. If the infection has been of a virulent nature 
ulceration of the mucosa and suppuration of the middle-ear 
are liable to supervene. 

Pseudo-membranous rhinitis is almost invariably diphther- 
itic in origin, as has been stated above. From the fact 
that constitutional symptoms are usually slight in primary 
diphtheritic, or fibrinous rhinitis, it frequently remains un- 
suspected until the membrane is accidentally discovered. The 
membrane may persist for weeks, coming away in large 
pieces. If during its course it be removed, it usually recurs. 
The nose is more or less obstructed, and a thin blood-streaked 
discharge runs from the anterior nares. Such a secretion 
should always arouse suspicion of diphtheria. On inspection, 
the membrane is seen as a firm, grayish exudate upon the 
interior of the nose. The disease is far more benign than 
faucial diphtheria with or without extension of the membrane 
to the nose, but it may assume a most unfavorable course by 
spreading to the pharynx, under which circumstance severe 
constitutional symptoms will aiise. 

Treatment. — In the early stages the obstruction may be 
much relieved by spraying or douching the nose with a warm 
mild alkaline antiseptic solution, such as Dobell's solution, or 
a normal saline solution, followed by spraying with a bland 
oil containing camphor or menthol in the proportion of one 
grain to the ounce. Later as the discharge becomes profuse, 
frequent cleansing of the nasal passages is imperative. In 
infants or young children who struggle against the use of 
the atomizer, a small glass syringe may be employed, inject- 
ing into one nostril and allowing the fluid to flow out of the 
other, the child lying on its side during the operation. 



DISEASES OF THE EAR, NOSE AND THROAT. 551 

In pseudo-membranous rhinitis a i to 1000 solution of per- 
manganate of potash should be used freely in the form of an 
irrigation, allowing about a pint to run through the nares at 
intervals of a few hours (see Nasal Syringing, Chapter I). 

In the early stages Aconite and Gelsemium are the most 
important remedies. In the snuffles of infants Dulcamara 
has given good results, and when associated with great em- 
barrassment of respiration, causing the child to start just as 
it is falling asleep on account of the extreme nasal stoppage, 
even in the presence of free secretion, Ammonium carb. is a 
most valuable remedy. Hughes {Manual of Therapeutics) 
considers Camphor a specific in the early stage, promptly abort- 
ing most cases and especially relieving the chilly feeling. 

Aconite. — Sneezing ; fever with restlessness and full pulse ; 
burning of the eyes. 

Gelsemium differs from Aconite in the absence of the rest- 
lessness and high arterial tension and in the predominance of 
malaise ; chilliness, especially creeps up and down the spine 
but not a well defined chill ; headache with drowsiness and 
heaviness of the eyelids ; aching in the muscles. Gelsemium 
colds are such as are contracted during warm moist weather 
or occurring in debilitated subjects ; the Aconite cold typi- 
cally occurs in active, plethoric individuals after exposure to 
cold winds. 

Nux vomica is indicated in the early stages of many cases ; 
there is dryness and obstruction of the nose ; fulness at the 
root of the nose and frontal headache ; cold hands and feet 
with a hot head ; anorexia and constipation ; irritability of 
temper and feverishness. Subjects who are overly sensitive 
to draughts. In this respect 

Arsenicum is similar. " Persons who are rarely without a 
cold " (IviNS). Sneezing ; profuse, watery, excoriating dis- 
charge ; tendency of cold to travel down upon chest. 

Belladonna has always been a most satisfactory remedy in 
my hands for the vascular engorgement of the turbinated 
bodies. The mucous membrane appears dry and bright red 
and the nose is much obstructed. 



552 DISEASES OF CHILDREN. 

Cepa. — Profuse, acrid watery discharge with lachrymation. 

Euphrasia has a profuse nasal discharge which is bland, 
but an excoriating lachrymal discharge, the opposite condi- 
tion of Cepa. 

Ferrum phos. is a valuable remedy in the early stages of 
coryza, being similar to Aconite, but without the feverish rest- 
lessness of that remedy. Given over an extended period of 
time it will do much to eradicate the cold-catching tendency. 

Sanginnaria Canadensis or Sanguinaria nitr. y 3X trit., is 
useful when there is a sensation of great dryness and burning 
in the nose and pharynx, with headache and loss of smell and 
taste. 

In the second stage, when the discharge becomes profuse 
and muco-purulent in character, no remedy is more useful in 
the majority of cases than Pulsatilla. When there is much 
soreness of the nose and evidence of ulceration Mercurius is 
the better indicated remedy. Hydrastis should be thought 
of, but it seems more useful in chronic cases. 

Pseudo-membranous rhinitis requires the remedies useful 
where croupous exudation is found. Hepar, 3X trit., and Kali 
bichromicum, 2x trit., will most frequently be of service. Local 
treatment as directed above is not to be neglected. A culture 
should be made and if it verifies the presence of the Klebs- 
Loefner bacillus, antitoxin should be used. 

SIMPLE CHRONIC RHINITIS AND PURULENT RHINITIS. 

Chronic rhinitis without pronounced hypertrophic or 
atrophic changes in the nasal mucous membrane is a com- 
mon affection of childhood. Abundant muco-purulent secre- 
tion is usually associated with the catarrhal process and 
makes the disease a particularly unpleasant one. 

In the etiology recurrent attacks play an important role. 
The period of childhood itself invites catarrhal inflammations 
with epithelial cell proliferation, the rapid desquamation of 
which constitutes the main pathological process in purulent 
rhinitis. It is not confined to those of the syphilitic or 



DISEASES OF THE EAR, NOSE AND THROAT. 553 

scrofulous diathesis, apparently healthy constitutions falling 
victims of the disease as well as others. As a predisposing 
cause, adenoids undoubtedly play the most important role. 
Unhygienic surroundings, and want of attention during acute 
attacks or failure to guard against the recurrence of such 
attacks are the chief exciting causes. No specific micro- 
organism is present, but there is no doubt that an infection of 
a mixed character causes the purulent inflammation. Irrita- 
tion by foreign bodies or other sources of irritation may 
induce similar pathological changes. 

Symptomatology. — The chief symptom is a profuse muco- 
purulent discharge. Xasal obstruction is not pronounced. 
The nose may become reddened about the orifices and excor- 
iated and crusts form in the anterior nares, usually at night, 
in this way inducing mouth breathing during sleep. Sus- 
ceptibility to acute attacks seems lessened on account of re- 
duced sensibility of the mucosa from less of epithelial cilia 

(IVIXS). 

Atrophic changes will occur in the course of years if the 
progress be not arrested. It may also pass into the hyper- 
trophic variety if rhinorrhcea has not been a prominent feat- 
ure of the case. In scrofulous children infection of the cerv- 
ical lymphatics is a frequent complication. In the majority 
of cases the prognosis is good, especial ly under proper treat- 
ment. Ozaena is the most unfortunate outcome that may be 
anticipated. 

HYPERTROPHIC RHINITIS; ATROPHIC RHINITIS. 

Hypertrophic rhinitis is a chronic catarrhal inflammation 
of the nasal mucosa and sub-mucosa, characterized by hyper- 
trophy of the turbinated bodies with resulting nasal obstruc- 
tion. It is not as frequently encountered in children as in 
adults, nor is it as common a disease as atrophic rhinitis. 
The pathological changes are- such as require a long time for 
their development, being a hyperplasia of the cellular ele- 
ments and overgrowth of the connective tissue and blood- 
vessels that form the turbinated bodies. 

36 



554 DISEASES OF CHILDREN. 

A variety of hypertrophic rhinitis in which there is simply 
engorgement and dilatation of the blood-vessels is not uncom- 
mon. In this class of cases a complete temporary retraction 
of the mucous membrane may be induced by the local appli- 
cation of cocaine, or it may occur spontaneously or as the re- 
sult of appropriate treatment. 

Atrophic rhinitis, or Ozcena, is characterized by atrophy of 
the nrncous membrane, of the cavernous structures, and the 
underlying bone. There is also atrophy of the mucous glands 
with consequent impaired function and the formation of offen- 
sive crusts. The crusts represent inspissated muco-purulent 
secretion which accumulates in the nasal chambers and un- 
dergoes decomposition. They are the cause of the fetor ema- 
nating from these patients. 

Etiology. — Adenoid vegetations play an important role in 
the etiology of hypertrophic rhinitis, by interfering with the 
drainage of the nasal chambers, thus inviting the accumula- 
tion of irritating material which keeps up a constant conges- 
tion of the mucous membrane. Again, the constitutional 
peculiarity which invites adenoids and hypertrophy of the 
tonsils predisposes to chronic catarrh and hypertrophy of the 
intra-nasal structures. Clinically there is an intimate asso- 
ciation of these conditions. Another cause will be found in 
recurrent acute attacks which may lead up to permanent 
structural changes. 

Atrophic rhinitis may develop as an independent affection 
or as a sequel to hypertrophic rhinitis. Casselberry dissents 
from the latter view, believing the transition of an hyper- 
trophic rhinitis an exceedingly rare, and in all events slow 
process ; and he looks upon atrophic rhinitis, particularly in 
children, as a distinct affection. A pronounced hereditary 
predisposition, moreover, has often been observed. Bosworth 
believes suppurative rhinitis of children to be the cause of 
atrophic rhinitis, the suppurative process destroying the mu- 
cosa layer by layer in the course of time, until eventually 
the deepest structures become involved. 



DISEASES OF THE EAR, NOSE AND THROAT. 555 

Symptomatology. — The chief symptom of hypertrophic 
rhinitis is nasal obstruction. This may be more or less com- 
plete and involve both sides simultaneously or alternately. 
Remissions occur, and frequently the nose will be clear un- 
der ordinary circumstances, only clogging up when irritated 
by the inhalation of dust ; walking in the wind ; entering a 
warm room, etc. This peculiar behavior readily explains 
itself when we remember that the obstruction depends upon 
the degree of vascular engorgement present at the time. 

As a result of the reflex irritation in the nose and the inter- 
ference with respiration, a train of symptoms indicating a 
disturbance in the general health of the child arises. Ner- 
vous irritability ; disturbed sleep and mouth breathing ; intel- 
lectual torpor ; haemicrania ; spasm of glottis ; asthma and 
enuresis, all may have their origin in the nasal stenosis. It 
is hardly possible to differentiate between the disturbances in- 
duced by hypertrophic rhinitis and those induced by adenoid 
vegetations ; the latter, however, are likely to induce even 
graver troubles than the former, and they are more frequently 
encountered as an independent condition. 

On inspecting the anterior nares we will find the turbinated 
bodies swollen and of a deep red color, the inferior turbinated 
being most readily seen and darker in color than the middle 
or superior. If there be much engorgement it will be impos- 
sible to see more than the inferior body and at the most the 
anterior half of the middle body without making an applica- 
tion of Cocaine to shrink the mucous membrane. Polypi are 
likely to be confounded with an hypertrophied turbinated 
body, but they are paler in color, are movable, and occupy a 
position between the turbinated bodies. 

Atrophic rhinitis is characterized by the formation of crusts 
and fetor. Obstruction of the nares only occurs if the crusts 
are allowed to accumulate in large masses. They may occur 
simply as scales, or form in large horny masses, completely 
occluding the nasal chamber. These masses eventually soften 
by decomposition or cause necrosis of the underlying mucous 



556 DISEASES OF CHILDREN. 

membrane, coming away in large masses and leaving an ulcer- 
ated surface behind. Trie fetor may be so intense as to render 
the patient's proximity unbearable. In the beginning the 
child may be annoyed by the odor, but eventually the sense 
of smell becomes so obtunded that it is not aware of the fetoi. 
There may be a sense of distressing fulness in the nose when 
crusts accumulate, and the habit of constantly picking the 
nose is soon acquired. Epistaxis is soon a frequent accom- 
paniment. The general health is naturally affected ; hearing 
becomes impaired, and the sense of smell may be entirely 
lost. 

Inspection reveals a spacious nasal cavity lined with a thin, 
smooth mucous membrane, covered with crusts. Its surface 
is studded with superficial ulcers. Hereditary syphilis is to 
be differentiated from atrophic rhinitis; in the former there is 
not a uniform distribution of the atrophic process, and there 
is deep ulceration and cicatrization. Perforation of the septum 
with sinking in of the nose is pathognomonic of syphilis. 

The prognosis is not unfavorable. Under persistent treat- 
ment most cases in children recover, some in the course of a 
few months, others not yielding to treatment in less than a 
year or two. Syphilitic cases, if seen early before destructive 
changes have set in, respond promptly to appropriate local 
measures in conjunction with anti-syphilitic remedies. 

TREATMENT OF CHRONIC RHINITIS. 

In undertaking the treatment of a case of hypertrophic 
rhinitis we must first of all determine whether it is an inde- 
pendent affection or due to adenoid vegetations. Should the 
latter prove the case we must proceed to remove the adenoids 
as directed under the article on Adenoid Vegetations. If the 
condition has not advanced beyond the stage of vascular en^ 
gorgement a cure usually ensues upon the removal of the 
adenoids. When permanent hypertrophy of the turbinated 
bodies has set in there is but one sure and permanent method 
of treatment that fulfills all the requirements of a safe and 



DISEASES OF THE EAR, NOSE AND THROAT. OO/ 

radical operation, namely, burning away the redundant tissue 
with the galvano-cautery. The inferior turbinated body is 
the obstructing body in the majority of cases, and by burning 
a linear eschar along its entire length, applying the platinum 
knife at the posterior border and drawing it forward slowly, 
burning down to the bone, sufficient retraction is obtained to 
overcome the stenosis. The operation can be performed en- 
tirely painlessly with the use of a 4 per cent, solution of 
Cocaine. In the course of a week or two the opposite side 
should be operated upon in the same manner. A mild anti- 
septic alkaline solution, such as Dobell's solution, or a solu- 
tion of Seller's antiseptic nasal tablets, should be used to 
cleanse the nose both before and after the operation. During 
the healing process it may be used either in a douche or in 
an atomizer, several times daily, to be followed by an oily 
spray, such as the Thuya Oil Spray made by Boericke & 
Tafel. 

Should haemorrhage occur after the cauterization or in the 
course of a day or two, when the scab comes away, it can 
readily be controlled by spraying with a 5 per cent, solution 
of the 1-1000 solution of Adrenalin, or by spraying with 10 
per cent, solution of Tannic acid. Packing is seldom required. 

Milder cases, not requiring surgical interference, should re- 
ceive local applications of Iodine and Glycerine (5 per cent.), 
made by means of absorbent cotton on a probe, about twice 
weekly, followed by spraying with thuya oil. Besides, the 
nose should be cleansed daily with the alkaline antiseptic, 
preferably by douching with the Birmingham nasal douche or 
any other similarly constructed appliance. It is always safer 
to follow the cleansing process with the oil spray to prevent 
catching cold. 

In treating atropine rhinitis the most rigorous steps for 
maintaining absolute nasal cleanliness must be taken. The 
free use of the douche bag is here to be instituted, and a pint 
of DobelPs solution should be allowed to flow through the 
nares at a time. This should be done twice daily. For the 
method of giving the nasal douche see page 19. 



558 DISEASES OF CHILDREN. 

If hard crusts have formed that cannot be dislodged by 
means of the douche, Hydrogen dioxid, diluted twice with 
warm water, should be slowly injected into the nares with a 
blunt syringe ; this so loosens them that they can be readily 
blown out. After the nose has been cleared a few drops of 
refined carbon oil with iodine (one grain to the ounce) should 
be dropped into each nostril with a medicine dropper (Kyle). 

When eroded surfaces remain after the removal of the 
crusts a stimulating powder, such as aristol, should be in- 
sufflated. Syphilitic ulcerations are best controlled by the 
local application of a ten per cent, solution of Nitrate of 
Silver. 

Remedies. — When well marked constitutional indications 
are present such remedies as Calc. phos., Calc. carb., the 
Iodides, Hepar and Silicea will give better results than rem- 
edies selected purely on local indications. Pulsatilla and 
Hydrastis are especially useful in simple, chronic and purulent 
rhinitis. 

In atrophic rhinitis the Chloride of Gold, Kali bichromicunh 
Mercurius corr. and Silicea are the most important remedies, 
Aurum heading the list. 

Syphilitic affections require Mercury, preferably the yellow 
iodide when the ulceration is confined to the mucous mem- 
brane. When the bones become affected Aurum metallicum 
is indicated. Ulceration of the septum calls for Kali bichromi- 
cum. Gummatous infiltration of the soft structures will re- 
quire the Iodide of Potash in material doses, five grains, three 
times daily, being the usual dose necessary to effect a cure. 

Alumina. — Thick, greenish-yellow nasal discharge ; anos- 
mia ; mind sluggish ; snapping in the ears when swallowing. 

Arsenicum iod. — Delicate, tuberculous constitution ; acrid 
discharge with burning in nose. Chronic purulent rhinitis. 

Aurum. — Offensive discharge ; soreness of bones of nose. 
Ozsena and syphilis. The metal seems best indicated in 
syphilis, while in ozoena the chloride is preferable. 

Calc. carb. — Glistening redness of nasal mucosa; extreme 



DISEASES OF THE EAR, NOSE AND THROAT. 559 

sensitiveness of nose ; purulent discharge. Chronic purulent 
rhinitis in scrofulous individuals. 

Calc. phos. — Chronic hypertrophic rhinitis in anaemic chil- 
dren or in association with enlarged tonsils and adenoids. 

Graphites. — Chronic catarrh, extending to the Eustachian 
tubes. Tendency to atrophy. 

Hepar. — Chronic purulent rhinitis with enlarged cervical 
glands. Hypersensitive to draughts. Uncovering the body 
brings on attacks of sneezing. 

Hydrastis. — Simple chronic rhinitis and purulent rhinitis. 
Abundant muco-purulent secretion with superficial ulceration 
of the mucous membrane. The discharge may also be stringy 
and tenacious. Post nasal dropoing. {Spigelia). 

Kali bichromicum. — Tenacious, yellow secretion ; ulceration 
of the septum. 

Natrum mur. — Simple chronic rhinitis. iw In all absence 
of clear indications for other drugs this is one of the best 
remedies where persons draw mucus from the posterior nares 
in the morning." — (Ivixs. ) 

Pulsatilla. — Chronic purulent rhinitis. Profuse discharge 
which is a bland, thick, yellow muco-pus, streaked at times 
with green. There is loss of taste and smell, and in order to 
act well there must be, according to Ivins, the typical Pulsa- 
tilla temperament. 

Silicea. — Ozai-na. Painful dryness of the nose ; ulceration 
with acrid, corroding discharge {Merc. sol.). Thick, fetid, 
post nasal discharge. Periostitis. The Silicea patient is pale 
and delicate ; predisposed to affections of the glands and 
bones that undergo rapid destruction ; in other words, it pre- 
sents the tuberculous type. There is also nervous hyperes- 
thesia and tendency to neurotic affections. 

ADENOID VEGETATIONS OF THE NASO-PHARYNX. 

The muco-lymphoid glands found in the vault of the 
pharynx and aggregated into a tonsil-like organ known as 
the tonsil of LushkOy or the pharyngeal tonsil, are in their nor- 






560 DISEASES OF CHILDREN. 

mal state of insufficient size to be readily detected, or to cause 
the least interference with free nasal respiration. Under cer- 
tain conditions, however, they become much enlarged ; in 
some instances a hypertrophy of such extent takes place that 
they fill up the entire naso-pharyngeal space, thus effectually 
preventing nasal respiration and giving rise to the pernicious 
habit of mouth breathing. 

No definite cause can be blamed for the development of 
this hypertrophic condition, as it is encountered in children 
of all descriptions, although the so-called scrofulous diathe- 
sis, or the more pronounced glandular diathesis, lympliatism, 
are the most frequent constitutional peculiarities found associ- 
ated with hypertrophied adenoids. L/ymphatism is in fact 
interpreted as a species of constitution in which there is a 
tendency to hypertrophy of the lymphoid structures through- 
out the body, in particular the tonsils and the lymphoid 
structure of the naso-pharynx and also hypertrophy of the 
thymus glands. For this reason the two conditions often 
go together. Hereditary influence also offers a predisposing 
factor, notably tuberculosis and syphilis in the parent. The 
period of childhood proper furnishes the majority of cases, 
but infants are not exempt. 

Chronic nasal catarrh ; deflections of the septum ; the ex- 
anthemata, and a damp, changeable climate furnish the causes 
which excite the hypertrophy of these glands in children pre- 
disposed thereto. 

The pathological changes encountered in the mucous mem- 
brane of the pharynx are an overgrowth of the muco-lym- 
phoid follicles and of the connective tissue in which they are 
embedded, together with increased vascularity and thickening 
of the mucosa. This hypertrophy leads to the formation of 
a large glandular mass which may attain sufficient size to en- 
tirely block up the naso-pharynx. According to the amount 
of connective tissue present and the mode of proliferation of 
the glandular elements, there will be either a soft, papilloma- 
tous growth, or a hard smooth mass, known as the individual 



DISEASES OF THE EAR, NOSE AND THROAT. 561 

variety, in contradistinction to the papillomatous, which is a 
multiple, pear-shaped mass. The individual variety is smooth 
and firm, while the papillomatous is soft and irregular in con- 
tour, conveying the impression of a bunch of earth worms to 
the examining finger. 

Adenoid vegetation belongs practically to the period of 
childhood, and after full maturity a physiological atrophy as 
a rule sets in, the pharyngeal vault being usually smooth at 
thirty-five, although it may be rough at as late a period of 
life as seventy (IviNS). 

Symptomatology. — Chronic nasal and pharyngeal catarrh 
is usually associated with adenoid vegetations, especially 
when the}- have existed for a long time. While a catarrhal 
affection of the nose and pharynx no doubt often acts as the 
exciting cause of adenoid tissue proliferation, still adenoids 
in themselves will set up catarrh through their mechanical 
interference with the circulation and normal breathing. The 
obstruction of the nasopharynx leads to lack of development 
of the frontal, sphenoidal, maxillary and ethmoidal sinuses 
with consequent narrowing of the face and upper jaw, which, 
together with the increased atmospheric pressure exerted 
upon the buccal surface of the palate due to lessened intra- 
nasal air-pressure and mouth breathing, leads to a gradual 
forcing up of the arch of the palate. This deformity re- 
sults in turn in deflection of the nasal septum, on account of 
the upward crowding of the base of the septum. In this 
manner the nasal obstruction is still further augmented and 
hypertrophic rhinitis is invited. 

Deafness from direct pressure upon the ostia of the Eus- 
tachian tubes or through an extension of the catarrhal process 
into the tubes is a frequent symptom accompanying adenoids. 

The physiognomy is characteristic and practically pathog- 
nomonic, and taken in conjunction with the alteration in voice 
and deafness a positive diagnosis can be made without even 
instituting an examination of the posterior nares. The 
upper lip becomes shortened from lack of development as 



562 DISEASES OF CHILDREN. 

a result of always having the mouth open ; the expression 
of the face is vacant and stupid ; the nose is pinched and un- 
developed and owing to the contraction of the superior max- 
illa the permanent teeth become irregular in distribution. 

When the condition has arrived at this stage there results as 
a natural consequence of the interference with the proper 
aeration of the blood and with the general nutrition headache 
and mental hebetude with a certain delicacy of constitution 
inviting the development of neurasthenia or even serious pul- 
monary disease. In children who are rachitic, pronounced 
deformity of the chest occurs on account of the associated 
bronchitis and the softness of the ribs. Even in the absence 
of actual deformity, the " flat-chest" is frequently encountered 
as a result of insufficient air supply to the lungs. In several 
instances I have encountered cases of pulmonary tuberculosis 
occurring in young adults which I feel might have been pre- 
vented had the chest been properly developed. This lack of 
development dated back to post-nasal obstruction by ad- 
enoid vegetations which caused in turn mouth breathing ; 
bronchitis ; chest deformity, and ultimately phthisis. (See 

Fig. 39-) 

Through reflex action, when in a state of irritation, ad- 
enoids in many instances bring on attacks of coughing, spasm 
of the glottis, and asthma. Bronchitis, due to vaso-motor 
paresis and irritation of the respiratory tract from mouth 
breathing, is one of the commoner complications of adenoids. 
Enuresis is a neurosis often depending upon adenoid irrita- 
tion. 

Diagnosis. — The presumptive evidence of adenoid vegeta- 
tions is found in the fancies and the nasal, non-resonant voice 
together with the associated symptoms of mouth breathing ; 
naso-pharyngeal catarrh ; partial or total deafness and re- 
tarded nutrition. Naturally these symptoms are only to be 
encountered in well-advanced cases; in incipient cases the 
age of the child and the development of the nasal obstruc- 
tions, not springing from an abnormal condition of the nose 



DISEASES OF THE EAR, NOSE AND THROAT. 



563 



proper, should always arouse a suspicion of adenoid vegeta- 
tions. The positive evidence of adenoids is obtained through 
palpation and posterior rhinoscopy. The latter procedure is 
quite difficult, practically impossible with some children. In 
others, however, a very satisf acton- view of the vault of the 
pharynx may be obtained, which is practically all that is 
necessary for a diagnosis, and much easier than obtaining a 
full view of the posterior nares. 




fig- 53- 



■MKTHOD. OF HOLD IXC, CHILD FOR PALPATING 
THE PHARYNGEAL VAULT. 



Digital examination is a simple procedure and should never 
be neglected. Especially when deciding to operate is it 
necessary to gain a thorough knowledge of the size and char- 
acter of the growth as well as its location in order that it 
may be thoroughly and intelligently removed. 

The mode of procedure is the following: Tress the child's 
right cheek against your side, encircling the head with the 
left arm and pressing the flesh of its left cheek in between 



564 DISEASES OF CHILDREN. 

the teeth in order to prevent it from biting down upon the 
examining finger. Now introduce the index finger of the 
right hand into the month and insert it into the pharynx be- 
hind the right fancial pillar, from which position it is then 
brought to the median line and to the vault of the pharynx. 
The procedure rarely induces dyspnoea, although the child 
usually struggles and gags with the finger in place. The 
papillomatous variety convey the impression of a bunch of 
soft, irregular growths. The classical description found in 
the text-books likens it to a bunch of earthworms. In the 
mirror it appears as a pale, reddish-gray pendant mass, usu- 
ally covered with a layer of greenish-yellow mucus. 

The hard variety imparts the feeling of a smooth, rounded 
mass, and appears in the mirror as a pale swelling with a 
smooth but more or less irregular surface. 

Treatment. — The importance of dealing with adenoid veg- 
etations promptly on the first intimation of their presence 
must appeal to every practitioner who has had opportunity 
to see the disastrous results of the presence of these, in them- 
selves benign growths. The condition is not to be met in a 
half-hearted manner, but a radical mode of procedure should 
be instituted from the beginning of taking the case. 

Remedies have yielded most satisfactory results in many 
instances, but in my experience the majority of cases are 
amenable only to operative measures aiming at a complete 
removal of the growths. Especially is this so in cases of long 
standing, where as a rule remedies accomplish very little. It 
is true that at the time of puberty a physiological atrophy 
sets in, but the harm that has been done in childhood — the 
period of growth and development — is of an irreparable 
nature. 

When a case is encounteied in its iucipiency remedies may 
be tried over a period of three months, unless urgent symp- 
toms are present, and if improvement follows and continues 
satisfactorily the operation may be put off or, possibly, en- 
tirely dispensed with. If, on the other hand, improvement is 



DISEASES OF THE EAR, NOSE AND THROAT. 565 

only slight or absent, the sooner the operation is performed 
the better for the child. 

Local treatment is difficult to carry out and its results are 
not satisfactory. 

Remedies. — The remedy which has given the best results 
in the majority of cases is Calc. phos. It is generally given 
in the 3d decimal trituration, a grain four times daily. If in- 
dications for one of the other lime salts are present, notably, 
the carbonate or iodide, they should be given in preference to 
the phosphate. 

Arsenicum alb. is useful for the catarrhal symptoms, espe- 
cially when associated with hypertrophic rhinitis and ear 
symptoms. 

Sanguinaria nitrate, 3X trit., has given excellent results. 
The indications are mainly clinical. " I have excellent results 
with this remedy and with Calc phos., the former locally and 
internally in the 3X trit., and the latter in the 30th or 200th, 
thus often avoiding operations." — (Ivixs. ) 

Personally I give Calc. phos., 3X trit., the preference over 
other remedies. The old school administers the Iodide of 
Iron with confidence and no doubt obtains good results ; the 
combination of Iron and Iodine is well indicated in man)- in- 
stances. 

The operation is most satisfactorily performed under a gen- 
eral anaesthetic, for with local anaesthesia it cannot be thor- 
oughly done, even in children who are willing to co-operate 
with the physician. Ether is the safer anaesthetic, but in young 
children Chloroform, unless contraindicated, is preferable, on 
account of its quicker action and because it does not cause 
increased mucous secretion in the throat like ether. Profound 
anaesthesia is, as a rule, unnecessary. 

The child being placed on the table upon its back and the 
shoulders elevated to let the head hang down, a mouth gag is 
inserted between the molar teeth on the left side. The oper- 
ator now stands on the right side of the patient and intro- 
duces the index finger of the left hand into the pharynx be- 



566 DISEASES OF CHILDREN. 

hind the soft palate in order to locate the growths. Having pro- 
ceeded so far he now inserts a Casselberry post-nasal forceps, 
guided by the left index finger, into the vault of the pharynx 
and seizes a portion of the growth, which is then torn away. 
Piece by piece, in rapid succession, the growth is removed, 
after which it is advisable to introduce a Gottstein or similar 
curette (Fig. 54) and scrape away the remnants which may 
have been left. 

Profuse bleeding follows, which is soon controlled by press- 
ure with cotton mops dipped in a saturated solution of Tannic 
acid and held against the bleeding surface by means of a long 
curved forceps. The blood also runs freely from the nose. It 
should be wiped away to permit nasal respiration to set in, 
which usually takes place immediately after the operation. 

Both before and after the 
operation the nose and pharynx 
should be sprayed with a mild 
antiseptic solution (Dobell's 
solution ; Seller's Antiseptic 
Nasal Tablets), and Aconite 
administered to lessen the in- 
fig. 54.— curette for the re- flammatory reaction. Acute 

MOVAL OF ADENOID .... • -i • 

otitis mav set in as a comph- 

VEGETATIONS. J . r 

cation, and if antiseptic precau- 
tions are not taken during the operation it may terminate 
in suppuration. The results of the operation are most grati- 
fying. Nasal respiration promptly ensues (unless the case 
has been of long standing), the blood becomes more thoroughly 
aereated, with resulting improvement in the color, and the 
appetite and general health, and reflex disturbances are re- 
moved. Naturally cases are encountered in which an opera- 
tion fails to benefit the child. Here, however, we must look 
for other lesions, notably, hypertrophic rhinitis and deflected 
nasal septum, as the cause of obstruction, either in part or 
in toto. Where, however, these can be excluded the results 
are uniformly gratifying. 




CHAPTER XVIII. 

CONSTITUTIONAL DISEASES. 
LITH^EMIA ; URIC ACID DIATHESIS. 

By the term " lithsemia " is represented a group of symp- 
toms resulting from the presence in the blood of certain 
products of faulty proteid metabolism. Most prominent 
among these substances is uric acid, and hence the condition 
is frequently spoken of as the uric acid diathesis. Closely re- 
lated to uric acid are the alloxuric bases, xanthin, hypoxanthin, 
guanin and adenin, and as the symptoms of lithsemia depend 
upon the retention of an excess of these substances in the 
body, the condition may be regarded as a form of auto-intoxi- 
cation, to which Rachford {American Text-book of Diseases 
of Children) applies the name of leucomain poisoning. 

Regarding the formation of uric acid in the body, Dr. Chas. 
Piatt (private communication) writes : " There are two 
theories current in explanation of the origin of uric acid in the 
mammalian body. i. That it is derived from the nucleinic 
bases, e. g., xanthin, hypoxanthin, guanin and adenin ; from 
those formed within the body and from those ingested with 
the food. 2. That it is derived from the amido-bodies, e. g^ 
glycocoll, leucin, tyrosin, etc.; that these are normally con- 
verted in the liver into urea ; that an interruption of this 
normal metabolism, ureids, e. g., hydantoin, allanturic acids, 
etc., are formed, and that these, in the kidney, are changed into 
uric acid. My own belief is that normally in mammals uric 
acid has a common origin with the nucleinic bases, viz., in the 
katabolism of the nucleoproteids ; that it is probably not de- 
rived from the nucleinic bases, neither from those of the bodv 
nor from those of the food ; that a certain percentage in 
health, and a larger percentage in disease, in conditions of 



568 DISEASES OF CHILDREN. 

disturbed metabolism within the liver, arises from the gly- 
cocoll, leucin, tyrositi, aspartic acid, glutamic acid, etc., which 
reach the liver, after absorption from the intestinal tract, via 
the portal vein. A circle which may easily become vicious 
is established by the fact that the glycocoll itself takes origin 
in the decomposition of the glycocholic acid of the bile. As 
regards the normal formation of urea, this is, for the mammal, 
the end-oxidation product of proteid metabolism, intermedi- 
ate steps in its formation being the ureids, alloxan, alloxanic 
acid, dialuric acid, parabanic acid, hydantoin, etc. A certain 
percentage results from the metabolism of the amido-acids in 
the liver, and a certain minute percentage from the uric acid 
carried to the liver by the portal circulation. The term ' uric 
acid diathesis ' is indefinite, sometimes convenient, often mis- 
leading, has no significance from a chemical standpoint, and 
yet may not be abandoned until our knowledge becomes more 
definite/ ' 

It seems probable that many of the manifestations of the 
lithsemic diathesis are due to the xanthin bases rather than to 
uric acid. It is a well established fact, however, that in cer- 
tain phases of the condition, known clinically as irregular 
gout, an insoluble urate is deposited in the tissues, causing 
characteristic symptoms. It may be shown, on the other 
hand, that many conditions, loosely designated as lithsemia, 
are, in reality, evidences of ptomain auto-intoxication or 
simply of hepatic insufficiency. Sedentary habits and over- 
eating will of themselves cause hepatic torpor, but it is rea- 
sonable to suppose that the descendants of gout}' ancestors 
migfht be cursed with a liver that was bad from birth. 

During childhood heredity plays the most important role 
in the etiology of lithsemia, as the other causes which may 
give rise to it in later life, viz., excessive proteid food, seden- 
tary habits, alcoholism, etc., are not operative during earlier 
years. Prolonged illnesses frequently lead to the establish- 
ment of this condition. 

Symptomatology. — Infants are frequently born with uratic in 



CONSTITUTIONAL DISEASES. 569 

farcts in the tubules of the renal pyramids ; these are washed 
out of the kidneys, and may be passed through the urethra or 
remain in the bladder, forming nuclei for vesical calculi. 
Older children may also have symptoms of uric acid precipi- 
tation — lumbar pains, renal colic, painful urination, haema- 
turia, and, very prominently, enuresis. Examination of the 
urine will usually reveal the crystalline deposits. 

The general symptoms of lithaemia are notably those refer- 
able to the gastro-intestinal tract, to the nervous system, 
and to the skin. 

Nausea and vomiting in recurring attacks, accompanied 
by fever, acute and chronic intestinal catarrh, and stubborn 
dyspeptic symptoms, belong to the gastro-intestinal disturb- 
ances. Convulsions, migraine, asthma and cyclic vomiting 
constitute some of the most prominent nervous manifesta- 
tions, while eczema is the well known cutaneous lesion of 
lithaemia. Disorders of vision are said to be of lithaemic 
origin at times. These conditions, strictly speaking, are in 
reality more the evidence of auto-intoxications than of gout. 

Lithaemic children are as a rule delicate, dyspeptic, nerv- 
ous, and excitable. They incline to be precocious and possess 
a strong tendencv to nervous and catarrhal affections. Im- 
perfect nutrition is the keynote to an interpretation of this 
constitution, which belongs to that group of morbid states 
known as arthritism (Bouchard), in which are included the 
principal constitutional diseases. 

The urine in lithsemia is usually scanty, high-colored, 
strongly acid, and deposits a large amount of uric acid and 
urates. Glycosuria and slight albuminuria are at times found. 
Lithaemic subjects frequently suffer from nephrolithiasis, and 
oxaluria may also be present. Before an attack the urine is 
often passed in large quantities, being almost colorless and of 
low specific gravity, indicating irritation of the kidneys with 
insufficient elimination of solids. 

While on the one hand lithaemia is frequently oxer- 
looked and the proper treatment consequently withheld, 
37 



570 DISEASES OF CHILDREN. 

still there is danger, on the other hand, of making a snapshot 
diagnosis of " uric acid diathesis " in an obscure chronic 
ailment. Hysteria and neurasthenia and their congeners, 
while they may be secondary to faulty metabolism, are 
in the majority of instances dependent upon hereditary 
defects of the nervous system, faulty education, bad home 
environment, or emotional causes (BarTXETT, The Clinical 
Relations and Diagnosis of the Uric Acid Diathesis, 
Medical Era, June, 1901). Other ailments which may be 
due either to uric acid or to terminal nerve irritations, 
such as post-nasal adenoids, phimosis and adherent clitoris, 
are asthma and enuresis. Auto-intoxication, or more cor- 
rectly speaking, exogenic intoxication from the intestinal 
canal, may produce cyclic vomiting, migraine or epilepti- 
form convulsions, but this is not lithaemia in the strict sense 
of the term. The xanthin bases, however, which are pro- 
duced directly within the blood-stream by katabolic changes 
in the cell nuclein of the leucocytes, are powerful poisons and 
may produce important disturbances. A careful examination 
of the patient must therefore always be made and all other 
conditions excluded before lithsemia can be diagnosed posi- 
tively. 

Treatment. — The diet is of the highest importance in 
lithsemia, for there are many kinds of food which contain al- 
loxuric bodies, either in the form of waste-prod nets or as 
nucleoproteids, and the introduction of these into the system 
only adds to the burden of the already overloaded tissues. 
For this reason all internal organs, such as sweetbreads, kidney 
and liver ; all meat-extracts or broths ; and raw 7 or cured meats 
should be absolutely forbidden. Indigestible articles, shell-fish, 
sweet wines and malted liquors should be withheld. Cooked 
meats may be allowed in moderation, but it is a fallacy to 
suppose that young meat is preferable to old. As a matter of 
fact, the contrary is true, for the flesh of young and growing 
animals contains more nuclein than does that of fullgrown 
ones. Hence beef and mutton are, theoretically, to be pre- 






CONSTITUTIONAL DISEASES. 571 

ferred to veal and lamb, but from the standpoint of di- 
gestibility the younger meats are more desirable. Poultry 
and fish are less likely to produce ill-effects than other kinds 
of meat. There is little difference between rare and well- 
cooked meats excepting one of digestibility. Sugar and very 
starchy foods should be given sparingly, because an excess of 
carbohydrates is apt to overtax the liver, which is usually 
impaired. The chief articles of diet should be milk, eggs, 
poultry, fish, oils and butter, fresh vegetables, fruit and the 
less starchy forms of cereal food. The patient should be 
encouraged to drink freely of water, preferably before or be- 
tween meals, to take plenty of out-of-door exercise, and to 
observe regular hours for sleep. 

The remedies that have proved of the greatest value in the 
lithaemic state in general are Berberis, China, Lycopodium, 
Natrum mur., Pulsatilla, Nux vomica, Sepia, Sulphur, Nitric 
acid and Benzoic acid. The symptoms on which these rem- 
edies are to be prescribed are their well-known gastric, urinary 
and temperamental indications. (See Treatment of Renal 
Calculi, p. 383.) The remedies which may be called for in 
the special manifestations of this dyscrasia are numerous, and 
the reader is referred to the chapters covering these cases in 
their therapy. 

A. C. Croftan, following a suggestion of von Noorden's, ad- 
vocates the use of Calcium in this condition. He prescribes 
it in the form of the carbonate, giving ten to fifteen grain 
doses two or three times a day, together with a full glass of 
water. This mode of treatment is based on the fact that 
Calcium, on account of its affinity for phosphoric acid, com- 
bines with this substance in the blood stream, forming a 
phosphate which is eliminated almost entirely by way of the 
intestinal canal. The phosphoric acid of the blood and of 
the urine is thus reduced, and the sodium relatively increased ; 
hence less mono-sodium phosphate and more di-sodium phos- 
phate is produced, and as the latter is the normal solvent of 
uric acid, this substance, instead of being deposited in the 
tissues, remains in solution and is eliminated. 



572 DISEASES OF CHILDREN. 



RICKETS ; RACHITIS. 



Rickets is a disease belonging exclusively to childhood, 
representing a pathological standstill in the normal process 
of ossification, with resulting softening and deformity of the 
entire osseous system. Associated with the lesions in the 
bones there is always more or less disturbance in the general 
health and malnutrition. The etiology is obscure and the 
course is essentially a chronic one. While some authorities, 
notably Kassowitz, claim that many infants show unmistak- 
able signs of rickets at birth, still the more recent workers in 
this direction doubt its occurrence much before the second or 
third month. Personally I have encountered a few cases that 
presented many of the clinical manifestations of rickets ap- 
parently from birth where the mother had been in miser- 
able health during the entire pregnancy. 

Foetal rickets has been described but it must be exceedingly 
rare. Stoeltzner {Pathologie u. Therapie der Rachitis, 1904) 
states that no such condition exists, although abnormal soft- 
ness of the diaphyses and swelling of the epiphyses may be 
observed in osteogenesis imperfecta and in chondrodystrophia 
fcetulis, 

The majority of cases develop during the teething period. 
After the second year it is rare, although it may be encoun- 
tered as late as from six to eight years (Schmorl). 

By far the most important etiologic factor is improper diet. 
The disease rarely develops in breast-fed infants unless lacta- 
tion be prolonged beyond the normal period. In my clinic 
I have repeatedly demonstrated rachitic manifestations in in- 
fants from one year to fifteen months old that were still on 
the breast. The reason for this is the deterioration of the 
milk which takes place under these circumstances. Arti- 
ficial feeding, however, is responsible for most cases. While 
a deficiency of lime salts in the food no doubt plays a promi- 
nent role in the production of rickets, as Bland Sutton dem- 
onstrated in his experiments with the lion cubs in the L,on- 



CONSTITUTIONAL DISEASES. 573 

don Zoo, still there are many other factors also to be taken 
into consideration. Clinical experience has taught us that 
deficiency in proteids and especially in fat, and a relatively 
high percentage of starch or sugar, is the usual diatetic error 
under which 'rachitis develops. Again, the improvement 
that takes place as soon as these percentages are properly ad- 
justed is corroborative evidence of the close relationship of 
diet to the disease. The persistent use of sterilized food, 
notably the proprietary foods, which, at the same time, are 
deficient in fat and high in carbohydrates, is an etiologic 
factor often to be encountered. 

The geographical distribution of rickets is more or less 
sharply defined. It is practically a disease of the temperate 
zone and its frequency rapidly decreases with a rise above 
sea-level, being quite rare in high altitudes. In large cities 
it is most prevalent, especially in localities with changeable 
and damp climate. In the cold and tropical climates it is 
practically unknown, and in the country districts it is rarer 
than in the cities. The claim is made that in some of the 
European cities from 80 to 90 per cent, of all children show 
evidence of rickets. 

Unhygienic surroundings; lack of fresh air and sunshine ; 
closely crowded quarters — these may be looked upon as con- 
tributing factors. 

ZweifePs theory that rickets is primarily a form of malnu- 
trition due to a deficient supply of lime and magnesium phos- 
phate in the food is controverted by the lack of improvement 
in these cases resulting from the addition of such salts to the 
food. Again, that rickets is not entirely due to deficient 
absorption of lime salts has been proved by Ruedel, who 
demonstrated through urinary analyses that rachitic infants 
absorb and eliminate lime as well as healthy infants. 

Again, the theory that certain acids, most probably lactic 
acid (generated in the intestinal tract), by lowering the nor- 
mal alkalinity of the blood to such an extent as to interfere 
with the precipitation of lime salts in the cartilages, does not 



574 DISEASES OF CHILDREN. 

seem to hold, as the alkalinity of the blood is not altered in 
rickets (StcELTzner, loco cit.\ Although changes in the 
bones, similar to rickets, have been induced by the feeding 
and subcutaneous injection of lactic acid (HeiTzmann, 
Baginsky), still in the cases experimented upon a diet poor 
in lime salts was at the same time administered. 

The role of heredity and of hereditary syphilis in the pro- 
duction of rickets can practically be ruled out, neither of 
them being essential to the development of the disease. 

The infectious theory is advanced by Morpurgo, who cul- 
tivated a diplococcus from cases of osteomalacia in rats and 
by inoculating young rats with the same obtained changes in 
the bones bearing a strong resemblance to rickets. 

According to Hagenbach rickets is due to some unknown 
micro-organism, his reasons for its infectious nature being (<?), 
the limited geographical distribution of the disease ; (£), its 
occasional epidemic appearance ; (V), its occasional acute on- 
set without any simultaneous change in the child's environ- 
ment or food (Stcextzner). 

Stceltzner sees in rickets a disturbance in the supra-renal 
glands, induced by some unknown miasm, but Wetter was 
unable to obtain any beneficial results from the use of supra- 
renal extract. 

That in rickets we are dealing with a form of intoxication, 
there seems to be no doubt. The pathological changes in the 
liver and spleen, and above all, in the blood, which are often 
pronounced, and the accompanying nervous disturbances, 
offer to my mind ample evidence of such a condition. 
Whether this be in the nature of an infection or of an auto- 
intoxication of intestinal origin it is impossible to say, 
although the latter seems to be the most plausible. 

Pathology. — The primary pathological disturbance in rick- 
ets appears in the periosteum. This accounts for the general 
sensitiveness of the body and the disinclination on the part 
of the child to use its extremities and its discomfort on being 
handled. This is followed by an irregular growth and distri- 



CONSTITUTIONAL DISEASES. 



575 



bution of the osteogenetic cells in the centres of ossification 
and absorption and irregular deposit of lime salts in the 
bones. 

The chemical composition of the bones is much altered. 
Thus, in the shaft of the tibia there is normally 21 per cent, 
water, in rickets 45 per cent. (FriedeEben). In the ribs the 
percentage may be raised from 44 per cent, (normal) to 66 
per cent. The most important alteration, however, is the de- 
crease in calcium phosphate. The ash (mineral constituents) 
may fall from 60 per cent., which is about the average in 
normal bone, to 30 per cent, or even lower. Such a bone 
can be readily bent or cut. 

The first demonstrable microscopical changes take place in 
the periosteum, being in the nature of an abnormal prolifera- 
tion of its cells. In the medullary canal, a fibro-cellular 
hyperplasia takes place which invades and replaces the medul- 
lary substance. The same process may affect the epiphyseal 
portion of the bone or even the diaphysis, leading to thick- 
ening and structural changes. 

At the extremity of the long bone, where the shaft and 
epiphysis are joined, growth is most active, for it is by the 
formation of new bone from the proliferating cartilage cells 
and their ultimate calcification that the bone increases in 
length. At this point rickets shows its most marked effect 
upon osteogenesis. The proliferating zone of cartilage cells 
is increased as are also the rows of cartilage-cell columns, 
which at the same time lose their regular arrangement. 
The zone of temporary calcification encroaches upon the 
upper layers of the cartilage and becomes interspersed with 
a net- work of blood-vessels, islets of uncalcified cartilage 
and osteoid tissue. The arrangement of the various struc- 
tures is thus greatly disturbed, this resulting from, in the first 
place, the irregular and hypertrophic growth of the cartilage ; 
secondly, the invasion of the cartilage by blood-vessels, and 
thirdly, the irregular calcification and metaplastic changes 
taking place in the ossification zone. 



576 DISEASES OF CHILDREN. 

In the medullary canal of the shaft, excessive absorption 
of lime salts takes place, the canal becoming abnormally 
large and the marrow being replaced with fibro-cellular and 
vascular tissue. The outer layers of the bone become thick- 
ened through excessive proliferation of the periosteum and 
the production of osteoid structure. In the flat bones, par- 
ticularly in the occipital bone, absorption of osseous tissue 
in small areas results in the production of craniotabes. 

These microscopic alterations in the structure of the bone 
explain its alteration in shape, namely the thickening of the 
shaft and the clubbing of the extremities, and also account 
for the change in the resisting power and in the consistency 
of the bone. 

With the arrest of the rachitic process, calcification of the 
cartilage sets in and the bone may become abnormally hard. 
The hypertrophic tissue in the centres of ossification and 
along the epiphyseal lines is absorbed to a great extent, so 
that the only permanent deformity which is left, as a rule, 
is the distortion and bending of the bone that took place dur- 
ing its soft stage. 

The soft structures of the body contain a normal amount 
of lime salts. 

Pathologic changes in other organs are not characteristic 
and constant. The liver may be enlarged. Splenic enlarge- 
ment, due to simple hyperplasia, is not uncommon. Anaemia 
may be pronounced. Catarrhal processes in the gastrointes- 
tinal tract and in the lungs may be associated with rickets. 

Symptomatology. — The characteristic deformities of the 
osseous system are the late symptoms of rickets ; and although 
they are pathognomonic, their advent should not be awaited 
before making a diagnosis of this disease. It is unfortunate 
if rickets is not recognized ere marked bone lesions have de- 
veloped, as the best opportunities for treatment have then 
slipped by. 

Rickets seldom develops before the sixth month, being 
practically a disease of the first dentition period. Its onset 



CONSTITUTIONAL DISEASES. 577 

is usually associated with more or less persistent diarrhoea, a 
moderate range of fever, fretfulness, restlessness, with ten- 
dency to kick off the covers, and local sweats. The develop- 
ment of anaemia, debility, profuse sweating about the head 
and chest, and general sensitiveness of the body to touch, in- 
dicates that the disease has become fully established. Con- 
stipation now gives place to diarrhoea, and the abdomen be- 
comes distended and prominent. 

There are cases in which the osseous changes are the first 
symptoms to attract attention, but they are in the minority. 
One of the earliest symptoms of rickets is disinclination on 
the part of the infant to lie on its back, as evidenced by con- 
stant rolling of the head from side to side and an effort to 
turn on the side. This is due to the sensitiveness of the peri- 
osteum covering the occipital bone. Associated with this is 
sensitiveness of the body and the local sweats, occurring 
mainly on the head. 

The entire muscular system is in an enfeebled, undeveloped 
condition. This accounts for the constipation, weak heart 
with sluggish circulation, and the rachitic pseudo-paralysis. 
This latter condition results directly from the ligamentous 
laxity, muscular feebleness and bodily tenderness ; and al- 
though some paediatrists incline to consider these cases a 
form of " pressure palsy," resulting from inflammatory 
changes in the vertebrae producing pressure upon the cord, 
still such a condition, if indeed it ever exists, must be a very 
rare and exceptional one. 

The first bony deformities to attract attention, as a rule, are 
the swelling of the wrists and ankles. As the disease pro- 
gresses the condyles of the femurs and the ribs become in- 
volved. There is, however, no fast rule as to the sequence in 
the development of the deformities, and rarely are all of the 
characteristic lesions found in a case. The ribs become 
beaded in their anterior extremity, at the junction of the rib 
with the costal cartilage. This deformity is described as the 
rachitic rosary, and it can be demonstrated in almost every 



578 DISEASES OF CHILDREN. 

case on post-mortem dissection, although to find it pronounced 
enough to be plainly visible and palpable is by no means true 
in all cases. Often the epiphyseal thickening of the rib is 
most marked on its under surface, and we will find well de- 
veloped rachitic changes at the autopsy that were not demon- 
trable in vitam. Owing to the softness of the ribs, the 
thorax becomes compressed laterally, with resulting projec- 
tion of the sternum ; this is the pectus carinatum, or chicken- 
breast. Another deformity of the chest is a groove encircling 
the lower portion of the thorax, the so-called Harrison's groove. 
This line corresponds with the lower border of the lungs and 
it is produced by recession of the lateral region of the soft, 
yielding thorax from atmospheric pressure, and the eversion 
of its lower border owing to the large, distended abdomen. 
These deformities become especially prominent as a result of 
diseases of the respiratory tract. 

Affections of the cranial bones are among the earliest signs 
of rickets Softening of the occiput, with areas of cranio- 
tabes, can be demonstrated, especially in the region of the 
lambdoidal suture. The occipital region becomes flattened 
as a result of the child lying on its back. The sutures are 
late in closing, the fontanel abnormally large, and the frontal 
and parietal centres of ossification are prominently thickened. 
These developmental peculiarities give to the head a large, 
square appearance, very typical of rickets. The head may 
also become misshapen and asymmetrical from lying more on 
one side than upon the other during the stage when the bones 
are soft and yielding. 

The softness of the bones of the palate and of the jaw pre- 
disposes to the development of deformities from the act of 
sucking and mastication. 

The spinal column suffers more or less in all cases of 
rickets. Owing to the softness of the vertebrae and weak- 
ness of the spinal muscles and lax ligaments, the child de- 
velops a kyphosis, when sitting up, which may result in a 
permanent deformity if the condition is not recognized and 



CONSTITUTIONAL DISEASES. 



579 



corrected. Rachitic kyphosis presents a curved outline, in- 
volving the greater portion of the spinal column, and in its 
early stages it can be entirely reduced by laying the child 
upon its stomach and making traction on the column by 
grasping the legs (see Fig. 12). The deformity of Pott's dis- 
ease is permanent, angular in outline, and involves only one 
or two vertebrae. Scoliosis may exist alone or in conjunction 
with kyphosis. 




FIG. 55. — CHILD WITH RICKETS, SHOWING I.AROK HEAD, NARROW 
CHEST, PROMINENT ABDOMEN AND OSSEOUS CHANGES. 



The extremities suffer from bending and twisting, as a re- 
sult of muscular traction or the weight of the body. The 
humerus and tibia suffer most frequently. Serious deformity 
of the pelvis rendering parturition difficult or even impossible 
is one of the unfortunate late results of rickets. 



580 DISEASES OF CHILDREN. 

The eruption of the teeth is delayed and irregular, and 
they may decay early on account of a deficiency or irregular 
deposit of enamel. Rachitic teeth are typically ridged in 
their long axis and sometimes present a saw edge. They 
must not be mistaken for syphilitic teeth. 

Rachitic children show a marked predisposition to a variety 
of ailments, referable to the nervous system, the alimentary 
tract, the skin and mucous membrane. Another notable 
peculiarity of rickets is its influence upon the course of acute 
illness in general — a disturbing factor, the recognition of 
which may prove of the greatest practical importance in the 
treatment of such cases. 

Among the disturbances in the alimentary tract compli- 
cating rickets, chronic indigestion, chronic intestinal catarrh 
and obstipation are of the most common occurrence. The 
mucous membranes in general are prone to catarrhal inflam- 
mation, characterized by a tedious course. 

The nervous system is particularly unbalanced and 
highly susceptible to peripheral impressions. Trifling ail- 
ments are liable to be ushered in with convulsions, and, in 
fact, convulsions occurring after the first year should always 
lead to a suspicion of rickets. Spasm of the glottis occurs 
almost exclusively in the rachitic. It develops after the sixth 
month, and continues until the second year, being intimately 
associated with craniotabes (Elsasser). 

The alterations in the blood are not constant and uniform. 
In all cases more or less anaemia is present, and in some, es- 
pecially those with splenic tumor, there may be leucocytosis 
with abnormal elements (myelocytes ; mast-cells and normo- 
blasts) in the blood. Some cases almost attain to the type of 
a pseudo-leukaemia. The tendency is to a reversion to the em- 
bryonic type of the blood elements as the above findings in- 
dicate. The haemaglobin and red cells are diminished in vary- 
ing proportions. 

The course of rickets is a chronic one, but the early insti- 
tution of treatment, together with the favorable influence of 



CONSTITUTIONAL DISEASES. 581 

fresh air and sunshine, will, as a rule, check the process 
promptly. After the rachitic state has become well established 
treatment yields slower results. 

Acute rickets has been described and Baginsky encountered 
two such cases, both accompanied by high fever and termi- 
nating fatally. Autopsy confirmed the diagnosis, positively 
excluding scurvy. This condition, like foetal rickets, must be 
exceedingly rare. Stoeltzner holds that it is impossible for 
rachitic bone changes to occur acutely. 

'Vh.^ differential diagnosis rests between hereditary syphilis; 
hydrocephalus ; Barlow's disease (scorbutus), and Potfs dis- 
ease. The differentiation of the last condition has been con- 
sidered above. Barlow's disease is a more acute disease, more 
frequently found in infants of the better classes as a result of 
exclusive feeding with proprietary foods, and is attended by 
swelling of the shafts of the bones, from sub-periosteal haem- 
orrhage, as well as joint-tenderness and swelling, besides 
ecchymoses in various parts of the body and haematuria. As 
this condition frequently becomes engrafted upon rachitis, 
its recognition may be attended with some difficulty. 

Epiphyseal disease and separation is a symptom of con- 
genital syphilis, which, however, occurs in the earliest months 
of life, other signs of syphilis being demonstrable. 

Chronic hydrocephalus presents a head more rounded than 
the rachitic cranium ; the face is disproportionately small in 
comparison with the head ; the eyeballs are deflected down- 
wards, and the mental condition is one of dullness and im- 
becility rather than precocity, as in rickets. 

The prognosis is usually favorable but it cannot be esti- 
mated in an off-hand manner. An uncomplicated case with- 
out pronounced deformity of the chest, anaemia and splenic 
tumor is generally promptly amenable to treatment, while those 
with such unfavorable symptoms especially in conjunction 
with laryngismus stridulus present a more serious prognosis. 
The occurrence of pneumonia or whooping-cough in a rachitic 
infant is most grave. Rickets also predisposes to tuberculo- 



582 DISEASES OF CHILDREN. 

sis, especially when there is chronic bronchitis and enlarge- 
ment of the bronchial glands. 

Treatment. — Prophylactic measures are to be directed to 
the mother during gestation, if rickets is hereditary in a 
given family. The child's diet is of the highest importance, 
avoiding the use of farinaceous food and giving a modified 
milk containing as much fat and proteids as the child can 
digest. It is not to be forgotten that breast-fed infants may 
develop rickets if weaning is not instituted at the proper 
time (before the end of the first year) in the case of delicate 
mothers whose milk is deficient in the above constituents. 
To early resort to solid food is to be deprecated. 

Fresh air and sunshine are other absolute necessities for 
the infant, and the scarcity of rickets in rural districts and in 
the tropics is a strong proof of the prophylactic power of 
these elements. 

In the early stages of rickets Calc. phos. undoubtedly stands 
at the head of the list of all remedies, both in the matter of 
frequency of indication and clinical value. The scrawny, un- 
developed infant, with flabby abdomen; diarrhceal stool con- 
taining greenish mucus, undigested casein and fat particles 
and organic acids ; delayed teething and craniotabes, closely 
corresponding to the incipient period of the disease. 

Later on, as the osseous changes, the anaemia, local sweat- 
ing about the head, glandular enlargements and distended 
abdomen become prominent symptoms, Calc. carb. is more 
applicable. 

The favorite old-school prescription is Cod-liver oil and 
Phosphorus. Of the value of the former as a food there can 
be no question, but I have obtained equally good results from 
the use of Olive oil, while phosphorus, when employed upon 
homoeopathic indications, particularly those referable to the 
nervous system and respiratory tract, invariably yields most 
beneficial results. Kassowitz has been able to demonstrate 
that Phosphorus exerts a specific, selective action upon 
the epiphyses of the long bones, inducing an iimamma- 



CONSTITUTIONAL DISEASES. 583 

tory process of the bone-forming cartilage at this point thus 
presenting the strongest resemblance to the rachitic process. 
On the strength of this he was the originator of the kl phos- 
phortherapie ,, in rickets, being championed by such pedia- 
trists as Demme, Soltmann, Jacobi and others. This is cer- 
tainly Homoeopathy, either blindly or wilfully unrecog- 
nized. Baginsky even goes a step further and states that it 
does not seem to help all cases alike, but chiefly those pre- 
senting laryngismus stridulus. 

Ferrum phos. is useful and perhaps more frequently indi- 
cated than Phosphorus, its well-known applicability in anaemia, 
bronchitis, febrile conditions and acute diarrhoeas making it 
an indispensable remedy at some period in the disease. 

Other remedies of importance are the following : 

Alumina. — Abnormal cravings or voracious appetite ; open 
fontanelles ; distended abdomen ; obstipation, from inactivity 
of rectum. 

Bell. — The nervous manifestations of rickets frequently 
call for this drug. 

Kali hydrojod. — Preliminary symptoms of rickets. Tender- 
ness of the entire body, but especially about the head. — 
(Cooper.) 

Mercurius. — Syphilitic ancestry; large head and open fon- 
tanelles; offensive, oily perspiration ; glandular enlargements ; 
tendency to catarrhal affections with ulceration ; curvature 
of the bones. 

Natr. mur. — Emaciation of the neck and thighs; anaemia ; 
slight pliability of bones. 

Silica. — Profuse sweating about the head and chest, with 
general sensitiveness of the body ; anaemia ; pale skin through 
which the bluish veins are prominently seen ; swelling of 
the epiphyses of the bones and affections of the cartilages in 
general ; skin dry and seal}-, with tendency to suppurative 
affections, notably paronychia. Silica is an important remedj 
in rickets, standing on the same plane with the Calcareas^ 
from which it must be careful! v differentiated. 



584 DISEASES OF CHILDREN 



Scurvy is a constitutional disease resulting from faulty 
nutrition, the infantile type of which assumes an acute course, 
with a superficial resemblance to rickets, for which reason it 
was formerly described as acute rickets and scurvy-rickets. 
The disease most frequently occurs between the ages of seven 
and fourteen months, although it has been seen at a much 
earlier period, one reported case being but four weeks old. 
{Amer. Pediatric Soc. Report of Infantile Scurvy, New York 
Med. Record, July, 1898.) In contradistinction to rickets, 
scurvy is encountered perhaps more frequently among the 
well-to-do than among the poorer classes, for it is among 
them that patent foods are more often used, the poor not 
being able to afford them. The immediate cause is un- 
questionably diatetic, the composition of the food being 
directly responsible for the development of the disease. 
Although it has been claimed that sterilizing or boiling the 
food is in itself a cause for scurvy, still there is not sufficient 
evidence to establish this as a fact ; and cases of scurvy de- 
veloping in children thus fed depend more upon the charac- 
ter of the food employed than upon the manner of its prepa- 
ration. It is almost invariably found that some form of pro- 
prietary food has been used either as a desiccated or a pre- 
served preparation. In rare instances scurvy has developed 
in infants at the breast and in some that were taking raw- 
milk, and, as Koplik points out, the method of preparing the 
food is of less importance than its composition. There must 
be something lacking in the food, but what this element may 
be we do not know. Besides the composition of the food, 
however, the question of its purity plays a most prominent 
role, and Dr. Nansen, among others, holds that scurvy is in 
its essential nature a form of chronic ptomaine poisoning. 
All of the cases that I have seen had been fed on some one of 
the well-known proprietary foods. 



CONSTITUTIONAL DISEASES. 585 

Symptomatology. — The characteristic symptoms of scurvy 
in infancy are anaemia ; sponginess and bleeding of the gums ; 
subperiosteal haemorrhages, notably of the lower extremities ; 
general sensitiveness of the body, and pseudo-paralysis of the 
extremities. 

The early manifestations of scurvy are a moderate amount 
of fever and painfulness of the extremities, most marked 
about the epiphyses of the bones. The child usually shows 
a rachitic tendency or actually has rickets, although the two 
conditions are entirely distinct. The gums are swollen, and 
may show petechial spots beneath their mucous membrane, 
or there is bleeding from about the teeth. The eyelids are 
often cedematous, but cutaneous haemorrhages are rare. 

The knee- and ankle-joints may become considerably swol- 
len and exquisitely tender, with discoloration of the skin. 
Swelling of the shafts of the tibia and femur can be elicited 
by palpation in severe cases. 

Hcnnaturia is at times the first symptom observed, and 
together with tenderness of the body may be the only symp- 
tom present. Morse {American Medicine) recently reported 
several such cases, and Barlow himself recognized this fact at 
the time he brought the disease before the notice of the pro- 
fession. 

The course of scurvy is an acute one, and under proper 
treatment it can be shortened to a few weeks. Fatal cases 
have occurred, especially in those whose true nature was not 
recognized in time. 

The diagnosis is not difficult when the characteristic symp- 
toms have developed, although it can readily be confounded 
with acute articular rheumatism in the early stages. Articu- 
lar rheumatism, however, is so rare in infancy that it should 
be the last condition thought of. 

Hematuria in infancy is always to be taken as strong pre- 
sumptive evidence of scurvy, and the application of the thera- 
peutic test, namely, fresh milk and lemon juice, will soon 
indicate whether we have been right or wrong. The hcembr- 
3« 



586 DISEASES OF CHILDREN. 

rhagic diathesis and syphilis under certain conditions may 
present symptoms similar to scurvy, but each of these dis- 
eases is sufficiently distinct in its clinical characteristics to 
be recognized as such, and here again the therapeutic test 
furnishes a ready means of differentiation. 

Treatment. — In the treatment of scurvy a change of food 
is demanded first of all. A milk formula suitable to the 
child's age, preferably unsterilized, and fed in definite quantity 
and at regular intervals, together with the administration of 
fruit-juice (two or three teaspoonfuls of orange-juice twice 
daily), are the dietetic requirements. Fresh-meat juice can 
also be given at regular intervals if anaemia and prostration 
are marked. 

Constitutional remedies are of the greatest value, particu- 
larly so when rachitic manifestations are present. The child's 
suffering can also be alleviated by remedies of an acute type, 
such as Agave Amer., Ferritin phos., Bryonia, Rhus tox. y 
Ruta and Mercurius. Deschere (N. Amer. Jour. Horn., Sep- 
tember, 1897) reports a case in which Calc. card, was pre- 
scribed upon the indications of profuse perspiration about the 
head and neck during sleep, sour odor from the mouth, and 
frequent, offensive urine, with immediate improvement of the 
condition. For the hgematuria, Phosphorus seems best 
adapted. 

STATUS LYMPH ATICUS ; LYMPHATISM. 

The status lymphaticus presents a condition of hyperplasia 
of the lymphatic structures throughout the body, especially 
affecting the solitary follicles and lymph nodes of the intes- 
tines. The mesenteric and bronchial lymphatic glands are 
much enlarged and there may be associated enlarged tonsils, 
adenoid vegetations and enlargement of the superficial lymph 
nodes. The spleen is enlarged and hyperplastic. The thymus 
presents a notable degree of hypertrophy, and it is this 
condition, which is the most important lesion of lymphatism, 
that is looked upon by many observers as being responsible 
for the various symptoms belonging to the disease. 



CONSTITUTIONAL DISEASES. 587 

Paltauf believes that the status lymphaticus offers a low- 
ered resistance to disease and that the sudden death is due to 
paralysis of the heart, while Jacobi clings to the belief that 
sudden death in these cases results from pressure symptoms 
(see p. 122). Hypoplasia of the heart and aorta has been 
observed in some of the cases. Blumer expresses the opinion 
that death results from a lymphotoxaemia, due to overproduc- 
tion of the internal secretion of the thymus. 

There are no symptoms characterizing the status lymphat- 
icus aside from the tendency to sudden death and attacks of 
asphyxia occurring in infants. The latter were described by 
Kopp nearly a hundred years ago as " thymic asthma." In- 
fants frequently die in these attacks. General lymphatic en- 
largment, markedly hypertrophied tonsils and adenoids and 
dulness over the manubrium sterni may hint at the condition, 
but this offers no positive evidence as hyperplasia of 
the faucial lymphoid tissues may exist in otherwise normal 
children. The disease is most frequently diagnosed at the 
autopsy and is only suspected when an infant dies suddenly 
without apparent cause or when an older child, previously 
healthy, succumbs to some trifling operation, from the effects 
of an anaesthetic, or dies within the first twenty-four hours 
of what has appeared to be an attack of congestion of the 
lungs or beginning pneumonia. Convulsions are frequently 
associated. 

scrofula; tuberculous adenitis. 

Scrofula in its fully-developed state is a chronic tubercu- 
losis of the lymphatics ; yet the scrofulous diathesis and many 
of its leading clinical manifestations may be encountered in 
case after case in the absence of demonstrable tuberculous 
lesions in any portion of the body. The general nutritive 
disturbance underlying the development of scrofula is respon- 
sible for the hyperplasia and the tendency to inflammatory 
changes in the lymphatic glands ; likewise the predisposition 
to obstinate catarrhal conditions and to certain cutaneous 



588 DISEASES OF CHILDREN. 

eruptions. The scrofulous diathesis invites tuberculous pro- 
cesses of slow and chronic type in the lymphatic glands and 
bones. The disease remains localized and it is more the ex- 
ception than the rule for a child with tuberculous arthritis or 
adenitis to develop a general infection from this source. 

Heubner {Kinder heilkunde, 1903) looks upon phlyctenu- 
lar conjunctivitis as the representative type of a scrofu- 
lous inflammation and he is of the belief that it results from 
infection with a minimal number of tubercle bacilli — the 
majority of which probably undergo dissolution and so act 
through the agency of their toxic proteids. For this reason 
it is impossible to demonstrate the tubercle bacillus in the 
secretion from such a catarrh. The chronic, intractable nasal 
catarrh of scrofulous children may have its beginning in a 
tuberculous infection of the faucial tonsil. The frequency 
with which tubercle bacilli lodge in the faucial tonsils and 
thence get into the cervical lymphatic glands is well known. 

Secondary pyogenic infection is another clinical manifesta- 
tion of scrofula. The lesions of the mucous membrane and 
of the skin soon become the seat of a " vulgar " infection — 
some form of pus micro-organism — and this leads to ulcera- 
tion or suppuration. When a tuberculous gland breaks down 
the necrosis is usually due to secondary infection of this 
nature. 

In the etiology of scrofula, as well as in every other dia- 
thetic condition, heredity plays the most important role. 
Parents who have themselves been scrofulous, or are tubercu- 
lous, give birth to children in whom this morbid tendency is 
likely to become apparent. So likewise carcinoma, syphilis, 
parental old age, or marked difference in the ages or close 
blood relationship of the parents, have been looked upon as 
etiological factors. Acquired scrofula may result from un- 
hygienic surroundings, especially when combined with im- 
proper feeding. The early abstraction of mother's or cow's 
milk from the child's dietary and a substitution of starchy 
foods is a potent factor in the production and fostering of 
scrofulous manifestations. 



CONSTITUTIONAL DISEASES. 589 

The division of scrofula into two types, described as the 
erethetic and the phlegmatic, is likely to produce confusion, 
as the former represents the purely tuberculous diathesis, 
possessing none of the features of scrofula, but a strong ten- 
dency to the development of tuberculous affections of a rapid 
course and extensive distribution. 

Phlegmatic Type. — This represents typical cases of scrofula, 
i. e., children of coarse features who are predisposed to catarrh 
and skin diseases showing a strong tendency to recur or to be 
intractable to treatment, and they are subject to glandular en- 
largements in various parts of the body, especially in the 
cervical region (tuberculous adenitis). They are usually 
mouth breathers and have enlarged tonsils and adenoids. 
The nasal catarrh produces a hyperplasia of the glandular 
structures and inflammatory infiltration of the connective tis- 
sue of the upper lip, causing it to become large and protrud- 
ing (Henoch). Young children are usually fat and flabby, 
and the abdomen is prominent. The peripheral circulation 
is poor. 

Scrofula develops most frequently toward the end of the 
first dentition period. With the advent of puberty its active 
manifestations disappear, although in exceptional cases indi- 
viduals may remain scrofulous for a much longer time. 

The lymphatic glands which most frequently become in- 
fected with tubercle bacilli are the cervical, bronchial and 
mesenteric groups. 

They become enlarged from multiplication of the cellular 
elements and hyperaemia, later undergoing caseation or ab- 
scess formation (secondary infection). Simple hyperplasia 
results in the superficial lymphatics from infection through 
the skin (scabies ; eczema) or mucous membrane, or from the 
absorption of infectious material in diseases of the tonsils, 
ears or teeth. 

Disturbances in the mucous membranes are characterized 
by hypersecretion, the secretion being irritating and offensive, 
inducing eczema and lymphadenitis in adjacent parts. Ca- 



590 DISEASES OF CHILDREN. 

tarrhal affections are chronic in their course, and the naso- 
pharyngeal adenoid structures, as well as the tonsils, are 
hypertrophied. The dangers to the scrofulous child are 
ophthalmia and otitis. In the former, permanent injur)- to 
the cornea may be anticipated, while in the latter life may be 
endangered through the advent of mastoid disease. In some 
instances the otitis is tuberculous in nature, but most fre- 
quently it is pyogenic. 

The skin is principally attacked with impetiginous eczema ; 
beside this, lupus, prurigo and lichen are encountered. 

Affections of the joints are as a rule provoked by a trau- 
matism, and the resulting inflammation may end in destruc- 
tion of the joint. Scrofulous changes in the bones show 
themselves as a fungous osteitis or periostitis, the vertebrae, 
phalanges, the head of the femur and the lower end of the 
tibia being most frequently affected. These processes are 
purely tuberculous in nature, being invited by the peculiar 
vulnerability of tissue belonging to scrofula. 

The prognosis depends upon the character of the lesions 
presented. Tuberculous adenitis will be separately discussed. 
The catarrhal and cutaneous manifestations may prove stub- 
born in their course. The scrofulous bone affections are 
serious and when suppuration takes place they often lead to 
death from exhaustion, amyloid disease or general tubercu- 
lous infection. The last condition is always to be feared 
when extensive involvement of the bones or lymphatic glands 
is present. Involvement of the bronchial and mesenteric 
glands is a very much more serious condition than involve- 
ment of the superficial lymphatics. 

The diagnosis of scrofula rests upon a recognition of the 
diathesis already described and the characteristic lesions found 
in the lymphatic glands, the skin, mucous membranes and 
bones. As these localities are also affected in a specific man- 
ner by syphilis, the differential diagnosis rests between these 
two diseases. A careful comparison of hereditary syphilis 
and scrofula must, however, remove any doubt as to the na- 



CONSTITUTIONAL DISEASES. 591 

ture of a given case. Thus, for eNample, the rhinitis of 
syphilis develops in early infancy ; it is accompanied by 
ulceration and destruction of the nasal septum, a result never 
obtained in scrofulous coryza. The symmetrical, mixed lesion 
of the skin, the moist condylomata and fissures of syphilis, 
are, again, quite distinct from the scrofulodermata, and the 
osseous changes appear as osteoperiostitis of the long bones 
(notably affecting the tibia) and osteochondritis of the epiphy- 
ses, never resulting in caries and destruction of joints, as in 
tuberculous osteitis. 

Adenitis. — Acute adenitis is most common in infancy ; 
tuberculous adenitis in childhood. Acute adenitis may be 
primary, but most frequently it complicates one of the acute 
diseases. The secondary form rarely undergoes suppuration 
excepting when it complicates scarlet fever. Primary cases 
are usually the result of a cryptogenic infection through the 
skin or buccal mucous membrane and, as a rule, break down. 

Tuberculous adenitis may run an acute or chronic course. 
The acute variety may become generalized, but it is a rare 
form. There is another form of generalized tuberculous 
adenitis in which successive groups of glands become in- 
volved, the course bearing a close clinical resemblance to 
Hodgkin's disease. 

• Local tuberculous adenitis is the commonest variety. Its 
characteristic features are chronicity and its tendency to 
spontaneous healing. The commonest form is cervical adenitis, 
usually associated with enlarged tonsils and adenoids. It 
is frequently encountered in poorly nourished children and 
represents the typical case of scrofula. The glands may break 
down and suppurate, producing ugly scars in the neck, or they 
may undergo sclerosis or calcification. This form of tuber- 
culosis rarely sets up a general infection and there is no direct 
relationship between cervical adenitis and pulmonary 
tuberculosis. 

Tracheo-bronchial tuberculous adenitis is more serious than 
cervical adenitis, as it may result in ultimate infection of the 



592 DISEASES OF CHILDREN. 

lungs. It is, however, frequently encountered in apparently 
healthy children that come to autopsy from some acute illness. 

Mesente7 r ic tuberculous adenitis is usually associated with 
tuberculous ulceration of the gut, although in some cases the 
latter only shows catarrhal manifestations. Its effects upon 
nutrition are marked and general infection or death from 
marasmus is the usual outcome. A moderate degree of 
adenitis of tuberculous origin may, however, be demonstrated 
in many instances in children dying of some acute illness. 

Treatment. — Children showing a predisposition to the de- 
velopment of scrofula must be put under a strict anti-scrofu- 
lous regime of hygiene and diet. In the prophylaxis and mod- 
eration of scrofulous manifestations an out-of-door life, par- 
ticularly a sojourn at the seashore, and a diet consisting 
mainly of milk, eggs, meat, and cod-liver oil, play the most 
important role. 

The remedies indicated upon a constitutional basis are the 
Calcareas, Mercury, the Iodides, and such other deep-acting 
drugs as Silica, Sulphur and Baryta. 

For the tuberculous lesions of the glands and bones I know 
of no remedy which will yield the prompt and positive results 
obtained from Iodoform. Administered in conjunction with 
the proper surgical treatment of such cases it hastens healing 
and prevents recurrence and extension of the process. The 
empirical use of Iodoform in a large number of scrofulous 
subjects has also demonstrated its efficacy in checking glandu- 
lar swellings and preventing their breaking down ; and a 
severe case of tuberculous osteitis of the tibia under my care, 
in which radical surgical measures combined with the admin- 
istration of apparently well-indicated remedies {Phosphorus, 
Silica and Auruni) failed to benefit the patient in the slight- 
est degree, was cured by Iodoform. Aside from its local action 
it seems to improve the patient's general condition, and es- 
pecially increases the appetite. 

The symptomatology of the following remedies demands 
especial consideration : 



CONSTITUTIONAL DISEASES. 593 

Arsen. iod. — Catarrhal discharges of an irritating and per- 
sistent character ; debility ; tuberculosis of the bronchial 
glands and lungs. 

Aurum met. — Caries of the bones ; foetid otorrhcea and 
caries of mastoid process ; retarded puberty. 

Baryta carb. — Baryta carb. is claimed to be related to a 
retardation in the development of both body and intellect. 
The glandular swellings are characterized by stony hardness. 
Beside this, enlarged tonsils and dry, scaly skin eruptions are 
prominent symptoms of the drug. The Iodide of Baryta is 
preferable in the throat affections of scrofulous children, al- 
though Calc. phos. is more useful than either of these salts in 
the majority of cases. 

Bell. — Acute symptoms of a scrofulous type referable to 
the eyes, ears, throat, lymphatics, etc. 

Calc. carb. — This remedy, which represents the leuco- 
phlegmatic temperament, gives us a perfect picture of scrofula 
in man}- of its phases. The catarrhal discharges from the 
nose, eyes and ears are offensive and irritating in character, 
and produce eczema and lymphadenitis in adjacent parts. 
The ophthalmia is very prone to become complicated by 
ulcerative keratitis, or phlyctenular make their appearance 
independently ; the otorrhcta may lead to caries of the tem- 
poral bone, and this, in turn, bring with it the danger of a 
cerebral abscess. The skin is dry and generally unhealthy, 
eczema developing from slight irritation, while suppuration 
readily sets in after an injury. The lymphatics become en- 
larged and tend to break down. The child is fat and pot- 
bellied, the latter condition depending chiefly upon intestinal 
torpor. Other symptoms frequently observed and strongly 
indicative of Calc. carb. are craving for eggs ; crusta lactea ; 
retarded dentition ; constipation with chalky stools. 

(ale. phos. possesses more of the true tuberculous element 
in its symptomatology, the child being emaciated and of a 
less sluggish type of constitution. The stools are especially 
important, being loose and offensive, and containing greenish 



594 DISEASES OF CHILDREN. 

mucus and undigested food-particles, hinting at intestinal 
tuberculosis. Caries of the bones has also been benefited by 
Calc. phos., and it stands in close relationship to Iodoform in 
both its intestinal and osseous disturbances. The Iodide is 
also an important remedy in its particular sphere. 

Graphites is one of the most useful remedies for the scrofu- 
lous skin affections, particularly when of the moist variety, 
with tenacious, yellowish exudations, accompanied by indur- 
ation of the superficial lymphatics. 

Hepar sulph., together with Mercurius and Silica, is re- 
quired in the suppurative conditions of scrofula. 

Silica is indicated in caries of the vertebrae and long bones 
when fistulous tracts have formed {Calc. sulph.\ and the pus 
is thin and offensive. The Silica child is pale and emaci- 
ated, the skin is thin and transparent, and the veins show 
through prominently. There is a strong tendency to the de- 
velopment of general tuberculosis, particularly when a local 
focus for infection is present. 

Phosphorus. — Thin, watery pus oozing from the diseased 
joint ; hectic fever; chronic diarrhoea ; nervous temperaments. 
Similar to Silica, although the Silica child is more apt to 
be of a fair complexion, presenting the anaemia and lack of 
animal heat so characteristic of the drug. 

Sulphur. — Dry, dirty, unhealthy skin ; irritating catarrhal 
discharges ; blepharitis ; aversion to being washed ; alternate 
diarrhoea and constipation ; eczema and prurigo ; emaciation, 
with voracious appetite. 

Surgical Treatment. — Extirpation of all tuberculous glands 
that are accessible was widely practiced some years ago, 
having been warmly advocated by Sir Frederick Treves, but 
the present concensus of opinion seems to be that it is better 
to leave these glands alone unless they break down and 
threaten to infect the surrounding structures, when they 
should be incised, all necrotic tissue carefully curetted away, 
and the wound then packed with iodoform gauze and drained 
in this manner until healing takes place. This is the mode 



CONSTITUTIONAL DISEASES. 595 

of treatment recommended by Prof. Wm. B. Van Lennep, and 
is to my mind far safer and more satisfactory than extirpation. 
I have seen prompt recurrence, usually in deeper or more un- 
favorable sites, after the most careful and skillful attempts at 
eradication. 

TUBERCULOSIS. 

Tuberculosis in infancy and childhood presents itself in 
widely different clinical types ; and as it may become a local 
as well as a general disease, it becomes necessary to describe 
many of its local manifestations under separate headings. 
Thus, tuberculous broncho-pneumonia is a condition de- 
scribed under the affections of the lungs ; tuberculous men- 
ingitis belongs distinctively to the nervous diseases; tubercu- 
lous ulceration of the bowels to diseases of the intestines, and 
the glandular and osseous lesions to scrofula. Still, each one 
of these affections is tuberculosis pure and simple; and in 
order to appreciate the full meaning of tuberculous disease as 
it occurs in childhood, it becomes necessary to study it as an 
infectious disease caused by the bacilius of Koch. 

It is noteworthy that infection almost invariably occurs in 
subjects presenting the tuberculous diathesis — a constitutional 
predisposition to the development of tuberculous processes of 
general distribution and more or less rapidly fatal course, re- 
sulting from transmitted hereditary tendencies, and reinforced 
by unhygienic and unfavorable surroundings. The question 
of diathesis is, therefore, a most important one, as its recog- 
nition offers suggestions immediately for both prophylaxis 
and treatment, as well as for prognosis. 

The tuberculous processes invited by the scrofulous diathe- 
sis are of a localized and chronic form, quite distinct from those 
invited by the purely tuberculous diathesis. In the latter, 
tuberculous processes in the lungs, brain and intestinal tract, 
or a general infection, are to be anticipated. Generalized 
tuberculosis is the most frequent type encountered in young 
children, infection taking place through the respiratory tract, 



596 DISEASES OF CHILDREN. 

the bronchial glands being attacked first, whence the process 
may reach every portion of the body through the channels of 
the lymphatics, the blocd-currents, and through auto-in- 
fection from swallowing bacilli-laden expectoration. In older 
children its manifestations more closely approach the clinical 
course pursued in adults. 

Primary infection through the respiratory tract is the most 
frequent mode of entrance of the bacilli into the system in 
infancy as well as in later childhood ; and although primary 
infection may take place through the alimentary tract from 
an infected food supply (milk from a tuberculous cow or from 
a tuberculous mother), still this is by no means as common as 
was formerly taught. In fact, Koch in his recent address be- 
fore the British Congress on Tuberculosis positively denied 
the possibility of the transmission of bovine tuberculosis to 
man. He cites the extreme rarity of primary intestinal 
tuberculosis in chldren, mentioning Biedert's 3,104 post- 
mortems with only 16 such cases ; Baginsky's experience, who 
never found intestinal tuberculosis without simultaneous dis- 
ease in the bronchial glands and lungs, and the reports from 
the Charite Hospital in Berlin, where in five years only ten 
cases were noted. Nevertheless, the necessity for sterilizing 
the child's food and particularly of weaning it from a tubercu- 
lous mother remains just as imperative as ever. 

Even infants who present no evidence of the tuberculous 
diathesis or a negative tuberculous family history are in 
danger of being infected on exposure to a phthisical patient. 
There is no lack of evidence to prove that children have been 
directly infected with tuberculosis either by inoculation, as in 
the instance of the Hebrew infants inoculated by a phthisical 
rabbi through the sucking of the wound during the ritual of 
circumcision (Lehmann) ; or by having lived in close prox- 
imity with a consumptive. A case bearing out the latter point 
is reported by Wassermaun in which an infant became tuber- 
culous after eight days' exposure. An ingenious theory 
against the validity of hereditary predisposition is advanced 



CONSTITUTIONAL DISEASES. 597 

by King (New York Med. Record, Oct. 12, 1901) and merits 
serious consideration. He believes that tuberculous parents 
transmit an immunity against the disease rather than a pre- 
disposition, and shows that children of tuberculous parents, 
although of frail constitution, have resisted invasion when 
under the same conditions children of non-tuberculous parents 
succumbed. In his belief, further, tuberculosis will eventually 
die out through natural selection and inherital immunity. 
He has also observed that tuberculosis in subjects with a 
tuberculous family history ran a slower course than in those 
without such a history, pointing to a partial immunity. 

Cases of congenital tuberculosis are on record, the mode of 
transmission being through the blood-current. Direct trans- 
mission through the ovum or spermatozoon seems possible, 
but no doubt this is exceedingly rare. Jani claims to 
have found the bacillus in the spermatozoa. Personally, 1 
encountered advanced tuberculous lesions in the lungs of an 
infant six weeks old, presenting caseation and fibrosis, strongly 
suggesting a congenital origin. Placental infection of the 
foetus has been observed a number of times. Martha Wollstein 
[Archives of Pedriatics, May, 1905) reports a case in detail in 
which advanced tuberculosis of the placenta was present, and 
the infant, which lived nineteen days, presented tuberculous 
lesions in the lungs and liver. The infection, judging from 
the histological findings, appeared to be haematogenous. 
Friedmann {Zeitschrift fin Klin. Med., 1901) injected an 
emulsion of tubercle bacilli into the vaginas of rabbits im- 
mediately after coitus and then examined the foetuses at dif- 
ferent periods of gestation. In all cases tubercle bacilli were 
demonstrated and from this he concluded that the foetus may 
be infected directly from the father. 

A latent form of tuberculosis is accepted by Baumgarten. 
In this the germs are supposed to be present in the tissues 
from the time of birth, not developing until favorable condi- 
tions, such as trauma or an acute illness, supervene. 

The role of heredity in the etiology of tuberculosis is, 



598 DISEASES OF CHILDREN. 

therefore, twofold. The disease may be transmitted directly, 
which is rare, or the child is endowed with the tuberculous 
diathesis, a frailty of constitution which predisposes its tissues 
to the ravages of the tubercle bacilli. Besides this, the child 
constantly breathes an atmosphere contaminated by the 
breath and sputum of the mother or of the several members 
of the household in whom the disease is active. It is, there- 
fore, no wonder that tuberculosis was generally believed to be 
a hereditary disease before the true causative agent and its 
mode of transmission were discovered. 

The large death-rate among infants from tuberculosis is 
appalling, the following statistics indicating the prevalence 
of this disease in early life : Comby {Klinische Therap. 
Wochenschrift, 1898) found tuberculosis in 12 percent, of a 
series of two hundred and thirty-five autopsies upon children 
up to the age of two years. None of these cases were under 
three months, showing the relative rarity of the disease in 
extreme early life — a strong point against direct hereditary 
transmission. Osier (Amer. Text- Book of the Diseases of 
Children) quotes Miller's statistics from the Munich Patho- 
logical Institute, in which one hundred and fifty cases in 
five hundred were tuberculous. At the New York Infant 
Asylum 8 per cent, of the cases were tuberculous, and in the 
Babies' Hospital 14 per cent. (Holt, Diseases of Infancy 
and Childhood.} The last statistics indicate that tuberculosis 
is not so frequent here as on the Continent. While not so 
prevalent among adults, still tuberculosis claims the greatest 
share of victims of all the fatal diseases that befall mankind. 
It has been estimated that one hundred and twenty thousand 
people die annually in the United States of consumption, 
tuberculosis of the lungs heading the list in all mortality 
bills. 

Pathology. — The morbid anatomy of tuberculosis demon- 
strates that the tubercle is not the only lesion indicating a 
tuberculous process. Although it is the typical product of 
an infection with Koch's bacillus, still another condition is 



CONSTITUTIONAL DISEASES. 599 

frequently observed, particularly in the lungs, where fusion 
of scattered areas of infection through exudative products 
and cell-proliferation in the alveoli result in large consoli- 
dated areas — the so-called tuberculous pneumonia. This is 
the form described by Laennec as infiltrating tuberculosis. 
The microscope reveals numerous non-vascular collections of 
cells, not aggregated into distinct nodules or tubercles, and 
separated from the healthy tissue by an ordinary round-cell 
infiltration. Again, the process may not rest with the forma- 
tion of tubercles, a reactionary or secondary inflammation 
resulting in adjacent parts. In the lungs such an extension 
of the process shows itself as bronchitis and peribronchitis of 
the smaller tubes with catarrhal (desquamative) or fibrinous 
pneumonic areas. 

Tubercles are divided into gray and yellow. The gray, or 
miliary tubercle, is the earliest stage ; it is a grayish, trans- 
lucent nodule about the size of a pin's head or millet seed, 
sometimes larger and of firm consistency. It consists of an 
aggregation of epitheliod cells surrounded by a zone of small 
round cells, or lymphoid elements. In the centre, multi- 
nucleated giant-cells are found. Their presence is character- 
istic of tubercle. The lymphoid elements are usually con- 
tained in a homogeneous fibrillated reticulum. As there 
is no vascular supply to the cell elements the}- soon break 
down, at first in the centre, undergoing fatty degeneration 
and necrosis, thus giving rise to the yellow tubercle. 

The termination of a tuberculous process is destined to be- 
come one of degeneration through coagulation-necrosis of the 
cellular elements, /. c, caseation. The lymphatic glands 
break down, and caseous pneumonic areas and cavities are 
formed in the lungs as the result of this necrosis. In those 
clinical types characterized by a preponderance of the tuber- 
culous process in the meninges of the brain such a result is 
never obtained, owing 10 the rapidly fatal nature of the 
lesions. The other extreme — calcification of caseous lesions 
— is sometimes seen. 



600 DISEASES OF CHILDREN. 

The virulence of the bacilli seems to exert an influence 
upon the nature of the lesions produced. Thus, Dr. Wood- 
head found that in feeding pigs with milk containing tubercle 
bacilli, subjected to heat, but not sufficiently high to entirely 
destroy the vitality of the germs, a modified form of tubercu- 
losis was produced, in which the lymphatic glands and the 
joints were principally affected — a condition analogous to 
scrofula in children. 

Symptomatology. — The clinical course of general tubercu- 
losis depends upon the locality principally affected. As the 
bronchial glands are oftenest the seat of primary infection, 
the pulmonary type of the disease is the commonest encoun- 
tered. In infantile cases the lungs are almost invariably in- 
volved and the bronchial glands usually show the oldest 
lesions. But the thoracic condition may remain unrecognized 
until revealed by autopsy in cases presenting a preponderance 
of cerebral or intestinal symptoms. Meningitis occurs next 
in frequency to the pulmonary form during the third year, 
about one-half of the cases dying with a terminal meningitis 
(Holt) ; and although intestinal lesions are commonly found 
in conjunction with tuberculous disease elsewhere, they rarely 
exist as a primary condition. The meningitis may be sec- 
ondary to a tuberculous process of the glands or bones. 

Infantile tuberculosis may be divided into the acute miliary 
variety and a sub-acute or chronic, progressively spreading 
form which resembles marasmus in many of its clinical mani- 
festations. 

Children of the tuberculous diathesis show a peculiar 
habitus indicating a delicacy of constitution with low re- 
sisting power against tubercle invasion. This diathesis is 
hardly recognizable in early infancy, but it becomes especially 
prominent during the period of childhood proper, at which 
period tuberculosis runs a somewhat different course than 
during infancy, being more limited in its distribution and ap- 
pearing as a purer clinical type. This is exemplified in the 
great prevalence of distinct cases of tuberculous meningitis, 



CONSTITUTIONAL DISEASES. 601 

tuberculous broncho-pneumonia, tabes mesenterica, tubercu- 
lous osteitis and adenitis at this age. 

The diathetic characteristics are a delicate, frail appear- 
ance ; small, slender bones ; slight muscular development ; 
transparent skin, through which large blue veins are promi- 
nently seen ; soft, silken hair ; long eyelashes ; bright, languid 
eyes ; oval face. They are of a passionate and lovable dis- 
position, and the mind is active and precocious. In such 
children it requires but a slight provocation in the form of an 
acute illness, among which measles and whooping-cough 
stand most prominently, or a local catarrhal condition of the 
respiratory tract, to invite the outbreak of tuberculosis. 

(a) The acute miliary form of tuberculosis runs a rapid 
course, terminating fatally in from three to six weeks. The 
starting-point of the general infection is a local focus, the 
most common seat of which, as above stated, being the bronchial 
glands. Acute miliary tuberculosis is more common in in- 
fants than in children and adults. In its early stage it is not 
suspected, as the child shows no characteristic symptoms ex- 
cepting a febrile disturbance and perhaps a bronchial cough. 
In the true typhoid type the systemic infection is the most 
pronounced condition, local manifestations being proportion- 
ately slight in comparison to the toxaemia. 

With full development of symptoms the fever runs high 
and assumes a remitting type, the remissions occurring in the 
morning hours, as a rule. The tongue is furred and dry, and 
the lips may become cracked and bleeding. Hydroa develop 
in abundance in some cases. A characteristic symptom is 
dvspncea and cyanosis, and while there are usually present the 
physical signs of a general bronchitis, still the pulmonary 
condition, as determined by the physical signs, does not seem 
of sufficient gravity to produce the marked respiratory em- 
barassment. Diarrhoea, with distended abdomen, enlargement 
of the spleen and albuminuria are common symptoms. The 
urine gives the diazo reaction of Ehrlich, as in typhoid fever. 
The child becomes apathetic and stupid, and gradually sinks 

39 



602 DISEASES OF CHILDREN. 

into a state of coma and collapse, or death results from a 
terminal broncho-pneumonia or meningitis. 

The meningeal type is preceded in its onset by character- 
istic nervous disturbances, such as irritable mood, constipa- 
tion, cerebral vomiting, squinting and headache, and during 
its entire course there is a predominance of nervous phe- 
nomena. A tuberculous meningitis may run a purely clinical 
course throughout, or it may arise during the course of a 
general tuberculosis, thus only modifying the type of the dis- 
ease. The same may be said of the pulmonary type, in which 
there is a predominance of the manifestations of an acute 
tuberculous broncho-pneumonia. The development of a 
tuberculous broncho-pneumonia is invited by the acute infec- 
tious fevers, especially when they attack children of the tu- 
berculous diathesis. Measles, whooping-cough, influenza and 
typhoid fever are especially dangerous. As broncho-pneumonia 
so frequently complicates these fevers, the greatest care must 
be exercised in managing such cases. The picture is a famil- 
iar one, as it is seen but too often. An apparently broncho- 
pneumonia becomes tedious ; the temperature remits, leading 
us to suspect a malarial condition or even typhoid fever ; but 
the case continues, in spite of our best-directed efforts, 
towards a fatal termination. 

(b) The protracted form of general tuberculosis, in which 
gradual wasting is the leading feature. This is the most 
common form of tuberculosis in infancy, and furnishes those 
lingering, emaciated cases which crowd the wards of hospitals 
and foundling asylums, and which are seen in the slums and 
dispensary clinics so numerously. The lesions are found in 
the lungs, spleen, liver, bronchial and mesenteric glands, in- 
testines, kidneys and brain. In the lungs large areas of case- 
ous pneumonia and large caseous or sclerotic tubercles may 
be found; the bronchial and mesenteric glands are usually 
much enlarged, and when cut piesent a caseous and broken- 
down interior.. The spleen and kidneys and the capsule of 
the liver are frequently studded with miliary tubercles in 



CONSTITUTIONAL DISEASES. 603 

different stages of development, and the brain ma)- show 
coarse tuberculous deposits on its posterior surface or a ter- 
minal basic meningitis. 

The symptoms of chronic diffuse tuberculosis are those of 
progressive wasting, with here and there manifestations of a 
local disturbance due to the above-described lesions. It may 
develop idiopathically or follow an acute disturbance. 
Cough, indigestion and persistent diarrhoea may be present, 
or the child may be constipated and have a voracious appe- 
tite, at times manifesting promising signs of recovery, only 
to fail entirely sooner or later. As in the acute form, there 
may be a predominance of symptoms referable to the organs 
principally attacked ; thus, a thoracic, abdominal and cerebral 
type can be distinguished. The tuberculous child is ex- 
tremely emaciated, the chest is small and poorly developed, 
and the belly is large and prominent. These features, taken 
together w T ith the wasted limbs, the flabby, shrunken skin, 
and the bright, precocious expression of the face, make up a 
clear-cut picture not so easily confused with other types of 
disease. Fever is not necessarily present, but as a rule it is 
present at irregular intervals during the progress of the dis- 
ease, and in the terminal stage there is more or less continu- 
ous moderate elevation of temperature in association with the 
gradual appearance of evidence of broncho-pneumonic lesions 
in the lungs. 

Physical examination may reveal areas of consolidation and 
sometimes cavities in the lungs, enlargement of the liver and 
spleen and of the mesenteric glands. The tuberculous pro- 
cesses in the lungs are not confined to the apices, as in adults, 
being scattered in distribution and as a rule not so extensive 
in area and therefore more difficult to demonstrate. There 
is, however, a preponderance of apical over basic lesions, and 
a persistent broncho-pneumonic process in the apices is 
always to be looked upon as tuberculous. The first rales are 
frequently heard in the nipple region, anteriorly (HOLT). 

The disease usually terminates fatally within a few weeks 



604 DISEASES OF CHILDREN. 

from the time that positive evidence of a tuberculous process 
can be demonstrated, although the premonitory stage wasting 
and other indefinite symptoms may go on for months before 
the condition shows its true character. 

Diagnosis. — The diagnosis of the acute form is difficult in 
the absence of visible indications of tuberculosis, such as 
tuberculous adenitis and bone affections, or a clear-cut tuber- 
culous family history. From typhoid fever it is to be dis- 
tinguished by the irregular and remitting type of tempera- 
ture, the absence of rose-spots, the bronchitis and respiratory 
embarrassment and the prolongation of the fever beyond the 
third week to a fatal termination. The chronic or apyretic 
form simulates marasmus and congenital syphilis to a degree ; 
but here again the family history and the characteristic 
lesions of the skin and mucous membranes belonging to 
syphilis, and the old, withered look and gastro-intestinal dis- 
turbances of marasmus, with absence of fever and pulmonary 
symptoms, serve to distinguish these affections from tubercu- 
losis. Where pulmonary symptoms are present and it is 
possible to obtain sputum for microscopic examination, the 
presence of the bacillus will render the diagnosis a simple 
matter. For the method of obtaining the sputum see the 
section of "Diagnosis" under "Pulmonary Tuberculosis." 

Treatment. — The treatment of tuberculosis is hygienic, and, 
as far as remedial agents are concerned, nothing is to be ex- 
pected from them more than to palliate and ameliorate symp- 
toms as they arise. It is true, cases of tuberculosis of a be- 
nign type have terminated in spontaneous recovery through 
self-limitation of the process, and authentic cases have been 
controlled with well-selected remedies ; nevertheless, this is 
an exceptional result which should never be promised or con- 
fidently expected. 

Acute miliary tuberculosis is universally conceded to be 
beyond the pale of medical skill. A wider field of usefulness 
in medicines is found however, in the chronic form, in which 
life can be prolonged and suffering much relieved by carefully- 



CONSTITUTIONAL DISEASES. 605 

selected remedies, choosing from among those having a decided 
action upon the general nutrition, and those capable of controll- 
ing catarrhal conditions. Iodine and its compounds, especially 
the Iodides of Arsenic, Antimony and Tin, and Iodoform, 
unite both of these features. Besides these remedies, Hepar 
sulph., Calc, Lycopodium, Sulphur, the Calcareas, Tartar 
emetic and Phosphorus are frequently indicated for the bron- 
chial and general constitutional symptoms. In the abdom- 
inal type of tuberculosis the Iodide of Arsenic is a most val- 
uable remedy, both for the glandular swellings and the 
diarrhoea, and ample clinical reports are extant to verify the 
utility of the drug. Iodoform (3X to 6x trit.) has, however, 
given me such promising results in all tuberculous conditions, 
notably in the presence of glandular enlargements, and in 
chronic diarrhoea of greenish, watery, undigested stools 
that I give this remedy the preference above all others in 
these cases. Calcarea phos. is quite similar in its symptom- 
atology, and covers the above-mentioned condition in chil- 
dren of the Calcarea phos. type of constitution. Tuberculinum 
has been used with apparent success by a number of physicians. 
Feeding, climate and hygiene require careful considera- 
tion. An abundance of fresh air and sunshine is an absolute 
necessity both as a prophylactic against the development of 
tuberculosis and as an element in the successful care for 
these cases. Where circumstances permit the child should 
be taken to an equable and dry climate, not necessarily moun- 
tainous — the stimulating climate of the seacoast being very 
beneficial in cases not principally pulmonary in type. Lib- 
eral feeding is a most important element in the treatment ; a 
highly nutritious but easily digested form of diet is to be 
selected, and fat administered freely to check the abnormal 
tissue-waste. Cod-liver oil, when it does not disagree, is the 
best form of fat ; marrow fat, olive oil, butter and cream are 
desirable substitutes when called for. Infants often do best 
when the oil is administered by inunction. The milk formula 
should be adjusted to meet the infant's digestive powers, the 



606 "diseases of children. 

amount of fat and proteids being regulated according to the 
condition of the stools, the tolerance of the stomach and the 
degree of satiety obtained from the food, endeavoring to keep 
the percentages of both ingredients as high as is compatible 
with the case. Eggs, scraped beef, meat-juice and fresh vege- 
tables, beside the various cereals and thoroughly ripened 
fruits, particularly grapes, are allowable in older children in 
the absence of gastro-intestinal disturbances. 

rheumatism; acute articular rheumatism, or rheu- 
matic fever. 

The rheumatic diathesis is an inherited predisposition to 
certain forms of articular and abarticular phenomena in asso- 
ciation with general and constitutional disturbances charac- 
terized by retardation in the process of nutrition. Although 
closely allied to gout and its manifestations, still rheumatism 
must be distinctly separated from this diathesis, to which it 
bears but a superficial resemblance. Its acute expressions are 
being recognized more and more as the result of a specific in- 
fection. 

"Clinically, rheumatism may be divided into three classes: 
i, articular rheumatism; 2, rheumatism of other organs, 
either external or internal, constituting what may be called 
abarticular rheumatism ; 3, general, diffuse, non-circum- 
scribed rheumatism." (Lyman, Amer. Text-Book of Prac- 
tice.) To the first class belong acute and chronic articular 
rheumatism ; to the second the rheumatic affections of the 
skin, vascular apparatus, muscular system, respiratory tract, 
digestive tract and nervous system, many of which are local- 
ized and clearly recognizable as rheumatism. The general, 
non-circumscribed affections present an array of symptoms 
referable to the internal organs and nerves which, although 
not so sharply defined and readily classified as the other forms, 
still offer strong indications of this dyscrasia. Among them, 
chorea and hemicrania ; rheumatic neuralgia and neuritis ; 
intestinal indigestion and chronic diarrhoea, and catarrhal 



CONSTITUTIONAL DISEASES. 607 

affections in general, represent the important conditions en- 
countered. 

Etiology. — In the etiology of rheumatism heredity stands 
high as the predisposing factor. Chilling of the surface by 
exposure to cold, by getting wet, or a sudden change of temper- 
ature, acts as an exciting cause. The actual cause for the 
pathological changes is still a disputed question, and the 
infectious, the neurotic and the lactic-acid theory have 
their advocates. Lactic acid, it is well known, acts as an 
irritant when present in excess in the blood ; although 
the claims of Richardson in regard to the artificial produc- 
tion of endocarditis in dogs by the injection of lactic acid 
have not been substantiated (Cheadle). The question 
arises, How is the excessive formation of lactic acid ac- 
counted for? Alfred Mantle considers it a ptomaine pro- 
duced by the micro-organisms found in the blood of rheu- 
matic patients ; and, according to his experiments and those 
of Klebs, Cornil and Babes, the introduction of these micro- 
organisms into sterilized milk has resulted in the production 
of lactic acid. (Cobb, Trans. Am. Institute of Horn., 1897.) 
Viewed in this light, lactic acid is seen to be a result of rheu- 
matic infection, and not a primary cause for the disease. 
The latest neurotic theory, as advanced by Bigler (The Pa- 
thology of Rheumatism, Trans. Amer. Institute of Horn., 1897), 
defines the rheumatic diathesis as "an abnormal state of un- 
stable equilibrium in the thermogenic mechanism, the result, 
in the individual or his ancestors, of too frequent or too pro- 
longed stimulation by variations in the temperature to which 
they have been exposed. . . . Exposure to cold of any 
kind, if not continued too long, will not be followed by symp- 
toms of rheumatism in those not predisposed ; whereas, in 
the presence of the same cause, in the case of those whose 
thermogenic mechanism is in a state of unstable equilibrium, 
the reaction will become excessive, and the effects will first 
show themselves in the prodromal symptoms which charac- 
terize the onset of acute rheumatism/' He further endeavors 



608 DISEASES OF CHILDREN. 

to show how continued reaction leads to pyrexia, excessive 
metabolism and excessive fibrin and lactic acid formation, 
which in turn cause further disturbances. The theory is 
learned and ingenious, but it does not explain the patholog- 
ical changes of rheumatic fever, and particularly does it fail 
to account for the close relationship existing between rheu- 
matism and endocarditis, the latter condition being estab- 
lished without all perad venture as infectious in origin. Of 
the lesions of rheumatism Eichhorst so timely says, " He who 
has seen post-mortem examinations of acute articular rheu- 
matism is surprised how strongly the impression obtained at 
the corpse calls forth an infectious disease ; haemorrhages 
into the various organs ; cloudy swelling in the heart, liver 
and kidneys ; large, soft spleen, etc." {Handb. der Speciellen 
Path. n. Therap.) Further evidence of its infectious nature 
is seen in the epidemic appearance of the disease and its oc- 
currence as a house disease, Edlefszen reporting seven hun- 
dred and twenty-eight cases to four hundred and ninety-two 
houses. Direct hereditary transmission is another clinical 
fact substantiating this view, several authentic cases being on 
record. As to the bacteriology, nothing conclusive has yet 
been decided. Mantle {British Med. Jour., 1887) has dem- 
onstrated the existence of micrococci and bacilli in the blood 
and serous effusions, while Singer found staphylococci and 
streptococci in the urine. He considers the tonsils as the 
point of entrance of the infection, their anatomical structure 
and frequent inflammation as an initial symptom of rheumatic 
fever offering the grounds upon which this view is based. 
More recently he demonstrated the staphylococcus pyogenes 
aureus in a case of chorea with inflammation of the elbow, 
the condition having been preceded by follicular tonsillitis. 
This view, usually that rheumatism is due to a micro-organ- 
ism, most likely a streptococcus which gains access to the 
system through the tonsils, is also advocated by Menzer in 
his work on the etiology of acute articular rheumatism {Ber- 
lin, 1902). The miasmatic origin of rheumatism is main- 



CONSTITUTIONAL DISEASES. 609 

tainedby Maclagan ( 7ze/<?«/zW// Century of Practice ) y who likens 
it to a malarial infection. The relationship of scarlet fever 
to rheumatism is noteworthy, painful swelling of the joints, 
with or without endocarditis, not infrequently developing 
during the course of the fever. Arthritis, however, is not 
always rheumatism, and it is now generally recognized that 
there are a number of obscure conditions which fit, so to speak, 
into the gap between acute rheumatic fever and cryptogenic 
pyaemia. 

The result of the investigations with the etiology of acute 
articular rheumatism conducted in Dr. Osier's clinic have 
been discouraging. Cole was unable to confirm the presence 
of the diplococci or streptococci found by Poynton and Payne, 
Meyer -and others in the blood, in the cases studied at the 
Johns Hopkins Hospital. Osier dissents from the view that 
rheumatism is simply a mild pyogenic infection because 
rheumatic joints never suppurate and because salicylates have 
no effect upon such a process {Practice of Medicine, 1905). 

Symptomatology. — In describing the phenomena of acute 
rheumatism the term rheumatic fever is most appropriate, as 
it includes both the manifestations of the articular and abar- 
ticular form of the disease. Particularly does this apply in 
the case of children, in whom involvement of the joints is by 
no means an essential requirement ; in fact, absence of joint 
involvement is one of the peculiarities of rheumatism of chil- 
dren. And futhermore, I can confirm from my own experience 
that a severe arthritis is more frequently due to septic infec- 
tion, gonorrhoea (see pages 121 and 391) or tuberculosis than 
to rheumatism. Arthritis confined to a single joint and of a 
sub-acute or chronic type is usually tuberculous. Acute 
epiphysitis, due to congenital syphilis, may be mistaken for 
rheumatism. Here the inflammation is confined to the lower 
end of the humerus, radius or tibia, the joint not being involved. 

An endocarditis or pericarditis, or an acute inflamma- 
tory affection of the pharynx or respiratory tract, is at times 
the onlv indication of an attack of rheumatism. Vrtiearia> 



610 DISEASES OF CHILDREN. 

erythema, fibrous tendinous nodules and chorea are likewise 
frequent manifestations of the rheumatic diathesis. 

Acute articular rheumatism is usually of gradual onset, a 
moderate fever accompanied by tenderness and slight swell- 
ing of several joints indicating the nature of the complaint. 
Neither are the joints as highly inflamed and swollen as is 
the case in adults, nor is the fever so high and abrupt in its 
onset. The joints most frequently involved are the ankles, 
knees and wrists, but there is not that wide distribution of 
arthritis found later in life. The hip may be affected to- 
gether with the knee, thus closely simulating the symptoms 
of tuberculous hip-joint disease. I have seen such cases also 
mistaken for appendicitis and psoas abscess, owing to the fix- 
ation of the limb, pain, and fever; here, however, the .discov- 
ery of other sensitive joints and endocarditis, and a careful 
local examination, will readily indicate the correct diagnosis. 

It is no wonder that a serious endocarditis so often gains full 
sway before it is suspected, when we consider how great the 
liability to error and how slight the indications of the true 
nature of the case are in so many instances. For this reason 
it is well to investigate carefully the ordinary colds, fevers 
and growing pains of children in order to determine their 
true nature, particularly when they occur in rheumatic fami- 
lies. 

An attack of articular rheumatism runs a course of from 
two to three weeks under proper treatment and in the absence 
of complications. In a general way, it may be said that rheu- 
matism shows a tendency to attack more extensively the tis- 
sues of the growing child, and to manifest itself over a longer 
period of time than in adults. 

Endocarditis may exist alone as a symptom of rheumatism, 
or accompany the articular forms, whether severe or mild. 
If it is discovered as a primary condition, arthritis or chorea, 
particularly the latter, frequently follows in its wake. Note- 
worthy to mention is the strong relationship supposed to ex- 
ist between the development of fibrous tendinous nodules and 



CONSTITUTIONAL DISEASES. 611 

a progressive endocarditis. They were first described by 
Barlow and Warner. These nodules are mainly found about 
the joints, most commonly at the styloid process of the ulna, 
above the olecranon, and along the tibia and malleoli. In 
structure they are found to consist of fibrous tissue with an 
admixture of fibro-cartilage (Mayer). Notwithstanding a 
careful search for these nodules in every case of rheumatism 
and endocarditis in children coming under my observation, 
they have been but rarelv found, and consequently were of 
little service in diagnosis. 

Pericarditis is rarer than endocarditis, more commonly of 
the dry form, and more difficult to recognize than endocar- 
ditis. There is, however, more pain than in the latter, and, 
in the advent of effusion, more dyspnoea. 

Tonsillitis represents one of the types of rheumatic inflam- 
mation, and it is a common affection of rheumatic children. 
The inflammation is severe ; the attacks show a strong ten- 
dency to recur, and the accompanying fever depends upon 
the local condition. Involvement of the endocardium is 
possible. These are the features of all rheumatic inflamma- 
tions, and beside tonsillitis the children of this diathesis are 
subject to rhinitis, pharyngitis and sibilant bronchitis, any of 
which may develop from apparently the slightest provocation. 
When endocarditis follows upon an attack of acute follicular 
tonsillitis it is hardly fair to refer to this as a proof of the 
identity of follicular tonsillitis and rheumatic infection, for 
in such a case the endocarditis is more probably septic or 
toxic than rheumatic (see p. 346). 

Muscular rheumatism is only common in the form of tor- 
ticollis, other groups of muscles being rarely affected in child- 
hood. 

The cutaneous symptoms indicating rheumatism are the 
various forms of erythema, urticaria and purpura rheumatica. 
They may occur alone or appear in connection with other 
local manifestations of the disease. Some chronic forms of 
skin disease are also dependent upon the rheumatic diathesis, 



612 DISEASES OF CHILDREN. 

and by directing attention to diet and selecting a rheumatic 
remedy many intractable cases of infantile eczema are speed- 
ily relieved. 

Ancemia is a direct result of rheumatism, and children who 
have been repeated sufferers from any of the above manifesta- 
tions, usually exhibit a high degree of anaemia. Anaemia is 
especially noticeable in rheumatic fever. 

Chorea, hemicrania and gastralgia are among the prominent 
nervous disturbances resulting from the action of the rheu- 
matic poison upon the nervous system. Especially in chorea 
has the intimate relationship of the two conditions been so 
clearly demonstrated that little doubt remains as to the eti- 
ology of the majority of cases of chorea. Quite often other 
strong indications of rheumatism are present in these cases, 
among which endocarditis stands most prominently. 

Chronic Rheumatism. — Many of the foregoing conditions 
are chronic in their course or lead to pathological changes of 
a chronic nature, yet by chronic rheumatism proper is under- 
stood the chronic articular form. It is a rare disease of child- 
hood, resulting from an injury to a joint in the presence of a 
strongly-developed rheumatic diathesis, or through incom- 
plete resolution or the products of an acute inflammatory 
attack. Disability from muscular contractures is also liable 
to occur in rheumatics, particularly after strains or other in- 
juries to a joint. Chronic rheumatic arthritis is prone to be- 
come tuberculous. (Wright.) Stengel (Amer. Jour. Med. 
Sciences, March, 1903) has found chronic rheumatism more 
frequently in children than in adults. It is essentially a 
sequel of the acute form. The joints of the fingers are com- 
monly affected, but the lesions are not symmetrical, neither 
are there trophic changes in the skin covering the affected 
parts. 

Still's disease is a variety of arthritis deformans, encoun- 
tered in children. Together with the general enlargement 
of the joints there is swelling of the lymph nodes and of the 
spleen. The onset may be febrile. General thickening of 



CONSTITUTIONAL DISEASES. 613 

the soft parts is more pronounced than enlargement of the 
articular ends of the bones and there is no grating as in the 
adult form. Anaemia and wasting of the muscles is marked 
but there is no endocarditis. In some of the reported cases 
marked improvement in the condition of the joints was noted 
even after the disease had progressed in the usual manner 
for a year or two. 

Treatment.— For those of a rheumatic inheritance much 
can be accomplished in the way of prophylaxis. Careful at- 
tention to the matter of clothing the child, having it wear 
flannel undergarments, and especially avoiding wetting of 
the feet and exposure in damp weather, is of the highest im- 
portance. The great danger which threatens these children 
is cardiac involvement. Constitutional remedies will do a 
great deal toward erasing the tendency to rheumatic attacks 
and mitigating their severity. Benzoic acid, Calc. carl?., 
Lycopodium, Causticum, Kali liydrojodicum, Mercurius, 
Sulphur and Rhus tox. are remedies of this type ; they are 
frequently indicated upon purely constitutional symptoms, 
and will accomplish much in this direction. 

The diet is of importance. Starchy and saccharine foods 
must be used sparingly, and fresh vegetables, voting meats 
and fowl, milk and fat (cod-liver oil ; olive oil ; cream, etc.) 
are to constitute the main dietary. Remembering the strong 
tendency to anaemia, a highly-nourishing diet becomes im- 
perative. 

During acute attacks absolute rest in bed must be enforced, 
to save the heart and hasten the subsidence of joint-inflamma- 
tion. Meat should not be permitted at this time. When 
considerably affected, the joints may be bathed with diluted 
tincture of HamameHs or rubbed with chloroform liniment 
and wrapped in raw cotton. Hinsdale {Medical Century, 
Feb., 1902) has used an ointment consisting of one part 
salicylic acid in two parts lanolin with much benefit. 

The following are the most frequently indicated and most 
useful remedies for the various manifestations of rheuma- 
tism : 



614 , DISEASES OF CHILDREN. 

Aeon. — Fresh attacks. The early restlessness, fever and 
involvement of the joints is much benefited by Aconite, es- 
pecially when the cause can be directly attributed to chilling 
of the body. 

Apis. — Stinging and burning pains ; cedematous swelling 
of affected parts and synovitis. 

Arnica. — Intense soreness of the body; the bed feels too 
hard ; great dread of being touched ; scanty, red urine 
chilly when •moving in bed; great internal heat and sour 
sweats. 

Arsenicum. — Protracted cases. Pale swelling of affected 
parts ; profuse sweats ; great anaemia and prostration. Endo- 
carditis and pericarditis (advanced cases ; effusion, valvular 
insufficiency, oedema ; cardiac dyspnoea, etc.). 

Belladonna is frequently indicated for the febrile condi- 
tion ; general aching ; sore throat ; torticollis. Phytolacca is, 
however, more frequently indicated in rheumatic sore throat 
than Belladonna, and for the torticollis, Lachnanthes has 
proven useful in many cases. 

Be7izoic acid. — "Rheumatic diathesis in syphilitic or gon- 
orrhoeal patients. Urine high-colored ; ammoniacal, very 
offensive in many diseases." (Hering.) Tearing pains as if 
in the bones. 

Bryonia is one of the most useful remedies in articular and 
muscular rheumatism, as well as in the inflammations of the 
serous membranes complicating the same. In both of the 
latter conditions it is indicated early in the dry stage, as well as 
after effusion has taken place. Rhus tox. is frequently given 
when Bryonia is indicated, the mere symptom of restlessness 
leading to the choice of the former remedy. If we remem- 
ber that the Bryonia patient may become very restless from 
intense pain — motion, however, giving no relief, and the rest- 
lessness being worse before midnight — we will not make the 
mistake of confusing these remedies. 

Calc. curb. — Frequently indicated upon constitutional 
grounds. 



CONSTITUTIONAL DISEASES. 615 

Cimicifnga rac. — " Pronounced cardiac lesions, fibrous 
nodules, and muscular contractures due to inflammation of 
the tendons and muscle-sheaths." (Cobb.) 

Chamomilla. — Great irritability of temper ; excruciating- 
pains, worse at night ; the child tosses about and cannot be 
pacified. 

China. — Often indicated as a tonic. 

Dulcamara. — Chronic rheumatism ; marked susceptibility 
to changes of temperature. Also rheumatic cutaneous erup- 
tions. 

Ferrum phos. — Ferrum phos. and Colchicin are most effect- 
ive remedies in controlling the intense pains of acute rheuma- 
tism. Colchicin I have found more applicable to pains distinctly 
located along the course of important nerve-trunks, especially 
the sciatic, while Ferritin phos. corresponds more distinctly to 
joint-pains, either localized or shifting about. Ferrum phos. 
is, so to speak, a cross between Aconite and Bryonia in 
rheumatism, its action being as prompt and certain as either 
of these. It must also be thought of for the anccniia which 
is liable to develop. 

Guaiacum. — Rheumatic pharyngitis (Phytolacca affects the 
tonsils) ; rheumatic contractures. A useful remedy in chronic 
rheumatism. 

Hamamelis. — Great soreness of affected parts, especially of 
the muscles. The aqueous extract, or the fluid extract 
diluted, has won great popular favor as a local application, 
superseding such lotions as potassium nitrate and laudanum, 
lead-water and laudanum, etc. 

Kalmia I a ti folia is an important remedy when there is 
cardiac involvement. u Pains flitting from joint to joint 
with now and then a warning twang at the ' heart-string ' ' 
(Hinsdale). 

Mercurius. — Tearing pain, not relieved by sweat ; wor.se at 
night and from the warmth of the bed ; joints usually swollen, 
with pale, puff)' appearance of the same. General gastric de- 
rangement; coated tongue, showing imprints of teeth; foul 



616 DISEASES OF CHILDREN. 

breath ; collection of saliva in mouth with bad taste ; diar- 
rhoea. Extension to heart, lungs, pleura and meninges. 

Pulsatilla. — Shifting pains, flying from one joint to another. 
The joints are highly sensitive, but usually no visible signs 
of inflammation are present. The child is fretful and dis- 
posed to cry, frequently changing its position in bed, which 
gives temporary relief. The symptoms are usually worse at 
night and aggravated by warmth. Gastric derangements, 
such as coated tongue, absence of thirst, anorexia, loss of taste 
or bitter taste, alternate heat and chilliness, and catarrhal 
affections, are usually present. 

Rhus tox. — The pathogenesy of Rhus toxicodendron clear ly 
indicates that it has a wider range of usefulness in rheuma- 
tism than any other remedy. Its selective affinity not only 
for the joints and fibrous tissues, but its decided action upon 
the respiratory tract, the nervous system, the circulator}- sys- 
tem and the skin, stamp it as the remedy par excellence for 
any affection to which we may see fit to prefix the term 
" rheumatic," in the absence of strong, specific indications 
for other remedies. It is true, the symptoms of Rhus tox. are 
not so markedly localized as those of Bryonia, Phytolacca or 
Spigelia, being most suitable to that class of rheumatic dis- 
turbances designated "diffuse, non-circumscribed rheuma- 
tism," but nevertheless it may prove of use in any form, pro- 
viding its leading indications are present. They are : "Draw- 
ing, tearing pains in fibrous tissues, joints, and sheaths of 
nerves, attended with a sense of lameness and formication in 
the affected parts; with or without swelling and redness; 
caused by exposure to wet, damp weather, to rain, by bathing 
or a strain ; WORSE during rest and when commencing to 
move ; BETTER from continued motion and dry, warm, ex- 
ternal applications ; great restlessness." (C. G. R.) 

Sulphur. — Frequently of use as a constitutional or inter- 
current remedy. 

Sodium salicylate will certainly relieve the excruciating 
pains of rheumatism, but whether it materially shortens the 



CONSTITUTIONAL DISEASES. 617 

course of the disease or is of any value in the prevention of 
complications is still a matter of dispute with many leading 
old-school authorities. 

Cactus, Cimicifnga rac, Colchicum, Digitalis and Spigelia 
are indicated in cardiac involvement. (For the indications for 
these remedies see Treatment of Endocarditis, p. 351.) 

HEREDITARY SYPHILIS. 

In children syphilis is almost invariably an inherited dis- 
ease, although it may be acquired during parturition from a 
primary lesion of the vulva or subsequent exposure to infec- 
tion. This is usually the case when the mother acquires 
syphilis late in her pregnancy, for if the disease is acquired 
after the eighth month the child escapes direct placental in- 
fection. The term hereditary syphilis, strictly speaking, ap- 
plies to those cases in which the ovum itself is syphilitic, either 
from the existence of maternal syphilis or from infection 
by the semen of the father — germinal syphilis. In such, 
syphilis exists from the time of conception. The foetus may 
acquire syphilis later through placental infection, in which 
case it is known as congenital syphilis, but the distinction is 
of no clinical importance. Acquired syphilis differs from the 
above forms both in the manner in which the disease gains 
access into the .system and in the presence of the primary 
sore, or chancre, which is never found in inherited syphilis. 

A syphilitic child may be born of an apparently healthy 
mother through paternal transmission of the disease, and 
although such a child is a menace to the community from 
the great degree of contagiousness of the disease, still the 
mother may escape infection from her own infant (Colles* 
Lazv). There are, however, exceptions to this rule, and 
mothers have been known to become infected from their own 
infants, showing that they were perfectly healthy while car- 
rying a child with germinal syphilis. In the cases where the 
mother does not become- infected from her offspring it still 
remains an open question whether she acquires an immunity 
40 



618 DISEASES OF CHILDREN. 

through the foetus or whether she is really a subject of latent 
syphilis. Again, a child may be born of syphilitic parents, 
having escaped infection, and remain immune to the acquired 
form of the disease throughout life {Prof eta's Law). Until 
the true etiological factor in the disease shall be positively 
known and its biological characteristics fully understood, the 
subject of hereditary syphilis will be beset with more or less 
confusion of opinions. 

Barly or precocious hereditary syphilis may manifest itself 
in utero, leading to a miscarriage. Children showing active 
signs of syphilis at birth are seldom born alive. They may 
appear macerated, or the body be covered with an extensive 
bullous eruption. The majority of cases do not show exter- 
nal evidence of syphilis until several weeks after birth, but 
this almost invariably appears before the third month. The 
variety of hereditary syphilis described as syphilis hereditaria 
tarda by Fournier, in which the appearance of specific 
lesions is supposed to be delayed until after the third year 
of life, is not recognized by many syphilographers, they being 
of the opinion that the early manifestations in these cases 
were overlooked. Again, hereditary symptoms occurring in 
later childhood may be the result of an innocent infection 
{syphilis insontium). 

The pathological lesions of hereditary syphilis are well de- 
veloped in most of the internal organs. The lungs show an 
increase in the inter-alveolar connective tissue and prolifera- 
tion of the alveolar epithelium {pneumonia alba). The liver 
may be enlarged as a result of round-cell infiltration of the 
interacinous spaces and pericellular cirrhosis; there may be 
gummata (rare) or simple interstitial connective tissue pro- 
liferation. These changes begin in the periportal region and 
spread into the acini, invading them with new connective 
tissue and blood-vessels. 

In the bones, epiphysitis is a characteristic change already 
observed in the foetus. Other conditions will be referred to 
under the clinical manifestations of the disease. 



CONSTITUTIONAL DISEASES. 619 

Symptomatology. — One of the first symptoms observed in 
the syphilitic infant is the syphilitic rhinitis or "snuffles." 
This is a dry catarrh due to infiltration of the mucous mem- 
brane and it may lead to ulceration of the septum with the 
production of the "saddle nose." In severe cases the infants 
are emaciated and present bullous lesions on the palms of the 
hands and soles of the feet. This is soon followed by the 
development of diffuse infiltration of the skin with a tendency 
to scale ; pustules ; ulcerating lesions of the mucous mem- 
branes. In less virulent cases there appear at the end of a few 
weeks macular syphilides on the lower portion of the ab- 
domen and on the buttocks ; papules and pustules may co- 
exist. The pustules are especially common upon the face 
and buttocks. They have a tendency to ulcerate deeply, 
forming dark-colored crusts. The skin appears shrivelled, 
poorly nourished, and presents a brownish discoloration. 
Other symptoms are hoarse, plaintive cry ; mucous patches 
in the mouth, rhagades at the angles of the mouth, anal con- 
dylomata and gastro-enteric catarrh, inducing foul-smelling 
diarrhoea. The syphilitic child is under-developed and 
anaemic ; the face wears a characteristic old and anxious ex- 
pression. The internal organs, as mentioned above, are the 
seat of diffuse interstitial hyperplasia of the connective tissue, 
through which destructive changes are wrought in the paren- 
chyma of the liver, lungs, and digestive glandular system. 
These lesions are responsible for the malnutrition and event- 
ual death of the syphilitic infant, although it may die with 
symptoms of basilar meningitis. 

The later manifestations of syphilis, occurring in cases not 
so malignant from the beginning, and consequently surviv- 
ing, are those referable to the bones, teeth, organs of special 
sense and nervous system. It is readily seen how, in mild 
cases, slight early manifestations may be overlooked or for- 
gotten, and how, upon the development of symptoms after 
the third year — even as late as puberty — the nature of the 
case is not promptly recognized or suspected. 



620 DISEASES OF CHILDREN. 

In the osseous system epiphyseal osteochondritis and dactyl- 
itis may occur early in the disease. Osteochondritis develops at 
the epiphyses of the long bones and by interfering with the 
growth of the bone may lead to deformity. The symptoms 
of epiphysitis are acute and simulate arthritis. The child 
holds the limb as if paralyzed on account of the pain. The 
lower end of the humerus is most frequently involved. Dacty- 
litis presents a characteristic fusiform swelling of the fingers, 
also attacking the metacarpal and metatarsal bones. Ulcer- 
ation often results with the destruction of the bone and in- 
tegument. Hyperostosis of the tibia, resulting in rounding 
out of the tibial crest and curving of the shaft — the sabre- 
blade deformity — is very characteristic of hereditary syphilis. 
In rickets the sharp crest of the tibia remains unchanged, 
while deformities of the bone are most marked at its lower 
end. Cranial exostoses upon the frontal and parietal bones 
are also found in well-developed cases. 

The milk teeth are delayed and decay early ; the perma- 
nent teeth present pathognomonic signs first described by 
Jonathan Hutchinson, for which reason they are known as 
Hutchinson? s teeth. The upper central incisors are dwarfed and 
present a notch upon their cutting surface, while other teeth 
show the influence of stomatitis upon their growth (see Ab- 
normalities of the Teeth^ p. 127). 

Two other conditions to which Hutchinson has given 
much prominence are interstitial keratitis and otorrkcea. 
Otorrhoea or sudden deafness should always arouse a suspicion 
of syphilis. Interstitial keratitis is a frequent symptom of 
syphilis, developing at the time of puberty. 

Nasal deformity is a characteristic sign of hereditary syph- 
ilis as well as radiating linear scars at the angles of the mouth. 
The latter result from ulcerating mucous patches, while the 
former is due to diffuse gummatous rhinitis, with accompany- 
ing ozsena. 

Gummatous infiltration of the brain and cord may lead to 
a variety of disturbances in the nervous system. Meningitis; 



CONSTITUTIONAL DISEASES. 621 

epilepsy ; dementia paralytica ; tabes dorsalis and hydro- 
cephalus are among the most important nervous affections 
that can at times be traced to a syphilitic origin. 

As the syphilitic infant presents a characteristic old, with- 
ered look, so the older subject of hereditary syphilis may ex- 
hibit a diametrically opposite condition, namely, that of kl in- 
fantilism" (Fournier). The individual appears younger, 
both mentally and physically, than his age would indicate. 

The diagnosis of syphilis is not difficult in the presence of 
a clear family history and clean-cut consecutive manifesta- 
tions of the disease, but it frequently presents the greatest 
difficulty when isolated symptoms are encountered. In the 
first place, a history of miscarriages in the mother followed 
by the birth of a still-born infant or one that died of kt inani- 
tion" in early infancy is strong presumptive evidence of syph- 
ilis. Secondly, the presence of snuffles at birth is an import- 
ant symptom. An underdeveloped, wakeful, old- and un- 
happy-looking infant (in contradistinction to the bright 
appearance of the purely marantic infant) should always sug- 
gest syphilis and lead to a careful watch for such symptoms 
as hoarse cry. offensive diarrhoea, cutaneous eruptions, etc. 
The later manifestations of syphilis are all characteristic, and 
in the presence of such symptoms as Hutchinson's teeth ; 
radiating linear scars ; flattened nose-bridge ; dactylitis and 
interstitial keratitis, other symptoms are readily accounted 
for. 

The prognosis of syphilis becomes the more favorable the 
later and the more benign the earliest manifestations of the 
disease have made their appearance. Death from syphilis is 
quite common in infants, but after the sixth month there is a 
good chance for the infant to survive if its nutrition can be 
maintained at a good standard. Probably one-half of all 
syphilitic-bora children succumb before the sixth month. 
The longer life is sustained after that period, with the insti- 
tution of proper treatment, the greater are the chances for 
ultimate recoverv. 



622 DISEASES OF CHILDREN. 

Treatment. — The syphilitic infant is a menace to its sur- 
roundings, for, with the exception of its mother, it is capable 
of infecting anyone with the disease. The lesions in the 
mouth and the discharges from the nose or from ulcerating 
papules or pustules anywhere upon the body are the sources 
from which infection takes place. 

If a syphilitic history is obtainable, even before signs of 
the disease make their appearance, it is advisable to institute 
treatment at once. 

As to remedies, there are a number beside Mercury which 
are not only frequently indicated, but which are indis- 
pensable in the treatment of hereditary syphilis. Usually, 
however, Mercury is the best remedy with which to begin 
the treatment of fresh cases, as it corresponds to the majority 
of the symptoms of secondary syphilis, the stage in which 
hereditary syphilis first manifests itself. When rhinitis and 
laryngitis are the most prominent early symptoms, inducing 
the so-called " snuffles " and hoarse cry, Kali bicliromicum is 
indicated. So, likewise, numerous other remedies may be 
called for from the beginning on special indications. When 
using Mercury I have obtained the best results from the 
protoiodide, administering one to two grains of the second deci- 
mal trituration three to four times daily according to circum- 
stances. As Bartlett well advises, the administration of Mer- 
cury should be stopped very shortly after the disappearance 
of symptoms, for there seems to be no necessity for mercurial- 
izing the infant. In the late manifestations of hereditary 
syphilis the Iodide of Potash must frequently be employed in 
material doses. The smallest dose which will improve the 
case is the proper one to employ, and I know of authentic 
cases in which this remedy in potency has yielded prompt, 
curative results. u It can frequently be well followed or re- 
placed by the Iodide of Ca/carea or the Iodide of Arsenicum 
in lesions of the glands ; by Si/icea or Zincum or Sulphur in 
those of the nervous system ; and by Hepar sulpiiuris or 
Autum or Nitric acid in those of the osseous system." 
(Cobb). 



CONSTITUTIONAL DISEASES. 623 

Aurunt. — Tertiary manifestations ; exostoses on skull, tibia 
and bones of forearm ; dactylitis with ulceration ; caries of 
nasal bones; defective development of genital organs; infan- 
tilism ; mental depression. 

Baryta card. — Glandular enlargements; squamous syphi- 
lides. 

Hepar calc. sulpJi. — Hepar has always been considered a 
valuable antidote to the evil effects of Mercury, but aside 
from this it is a most efficient remedy for many of the purely 
constitutional manifestations of syphilis. Its well-known 
influence over suppurative processes renders it useful in 
pustular skin affections and in the early stages of bone ne- 
crosis. The symptoms, u soreness of the nose on pressure 
with red, inflamed eyes," hint at beginning caries of the nasal 
bones, and a similar condition is obtained in the bones of the 
skull and extremities as well. The sharp, sticking pains in 
the throat are similar to Nitric acid, but when this remedy is 
indicated there are other symptoms present by which a differ- 
entiation is not difficult. 

Kali bichromicum. — Snuffles ; harsh voice and hoarse cry ; 
deep ulcers on the edge of the tongue ; ulcers on the velum 
palati, eating through ; ulceration of nasal septum (cartilagin- 
ous portion) ; ulcers in general, with characteristic punched- 
out appearance. 

Kali hydroj. — Tertiary syphilis ; diffuse and circumscribed 
gummatous infiltrations ; mercurialization ; interstitial kera- 
titis ; otorrhcea ; swelling and ulcerative destruction of uvula. 

Kreosotum. — Foul-smelling diarrhoea ; the teeth turn black 
and crumble. 

Mercurtus. — As to the homoeopathicitv of Mercury to cer- 
tain stages of syphilis, this is a fact so firmly established that 
it requires no further discussion. An analysis cf the cases 
successfully treated with Mercury indicates that its most 
marked effects are the healing of ulcers and improvement in 
the general health, both of which belong to the truly homoeo- 
pathic action of the drug (Hughes, Pharmacodynamics). Its 



624 DISEASES OF CHILDREN. 

" tonic " action is owing to its haematic power, while its con- 
trol over diffuse inflammation and swelling of the mucous 
membranes, accompanied by ulceration and inflammations of 
serous membranes, periosteum and skin, depends upon its 
specific action upon these structures. This primary, specific 
action covers almost completely the early manifestations of 
hereditary syphilis, and the manifestations of mercurial abuse 
cover many of the destructive manifestations of the disease. 
Impetigo and rupia, rapid ulceration of the mucous mem- 
branes, skin and bones, etc., strongly call for Mercury, espe- 
cially in combination with Iodine, as recommended above, or 
in larger doses when symptoms become urgent (inunctions). 

Mezereum. — Pustular eruptions, forming thick, brownish 
crusts, with oozing of pus, painful at night; swelling of shafts 
of bones ; syphilitic neuralgia. 

Nitric acid. — Deep, irregular ulcers on border of tongue, 
upon tonsils and soft palate ; sticking pains in ulcers; rhagades 
at angles of mouth ; pustular and squamous syphilides ; mer- 
curial stomatitis and cachexia ; urine strong, ammoniacal ; 
condylomata. 

Sulphur. — Syphilitic children often require an occasional 
dose of Sulphur to arouse their reactive powers or to control 
special symptoms. The symptomatology of this remedy is 
too extensive to be considered here, its sphere of action em- 
bracing both general and special indications. Psorinum may 
likewise be called for occasionally. 

Thuja. — Flat, condylomatous lesions about the anus and 
ulcerating papules on the scrotum. 

MARASMUS, OR ATHREPSIA ; MALNUTRITION. 

The extreme form of malnutrition in infancy leading to 
actual starvation is more often seen in hospitals and dispen- 
saries than in private practice. Aside, however, from this ap- 
palling athrepsia, or marasmus, there is a large class of 'in- 
fants in whom the nutrition is simply below par, but whose 



CONSTITUTIONAL DISEASES. 625 

condition tends to become progressively worse unless active 
measures are taken to restore the balance of the physiological 
process of normal growth. 

The pathogeny of infantile athrepsia is as obscure to-day 
as it was in 1877 when Parrot described the conditions as an 
independent disease following in the wake of gastro-intestinal 
disturbances and due to certain changes in the blood through 
which a reversal of the process of nutrition is effected and 
such pathologic processes as aphthae, cutaneous eruptions, 
fatty infiltration of the liver and uric acid infarcts of the kid- 
neys are produced. 

The histological findings in the gut are by no means uni- 
form. Baginsky insists that the mucosa is thinner than nor- 
mal and that there is distinct evidence of atrophy of the in- 
testinal tubules and villi. Heubner, on the other hand, claims 
that pathological changes are not constantly found and when 
so, that they are only the evidence of a preceding enteritis. 

On the other hand, the long-continued distention of the gut 
with gas as a result of fermentation accompanied by the wast- 
ing of its muscular coat produces the appearance of a glandu- 
lar atrophy. The careful investigations of Holt substantiate 
the view that there is no definite gross pathological lesion in 
the intestinal mucous membrane to account for the clinical 
manifestations. 

The theory of a chronic acid intoxication of intestinal ori- 
gin was advanced by Keller, who found the urine highly acid 
and containing an excess of ammonia. The origin of these 
acids lies in a deficient oxidation of the carbohydrates and 
particularly the fats of the ingested food. The fact, however, 
remains that this excessive elimination of ammonia has been 
found wanting in a number of cases of gastro-intestinal 
atrophy and has been repeatedh found in the absence of any 
distinct signs of wasting. In a number of my own cases the 
urine has been excessive in quantity and of very low specific 
gravity. The only abnormal chemical change noted was an 
increase in indican. 



626 diseasp:s of children. 

Arguing from the established fact that the intestinal mu- 
cosa of a marantic infant assimilates the proteids and fats of 
an artificial food much less satisfactorily than breast milk and 
consequently expends a much greater amount of glandular 
energy in this attempt, Heubner explains the failing nutri- 
tion on the grounds of a disturbed balance of energy, in other 
words, waste of energy on the part of the organism. 

My personal investigation of the gastric contents of cases 
of marasmus (Hahnemannian Monthly, May, 1903) has shown 
that in a well developed case there is a total absence of free 
HC1. and that the amount of free hydrochloric acid in less 
pronounced cases bears a definite relationship to the progno- 
sis. Indeed, where the emaciation is the result of some other 
disease, such as tuberculosis, I found more or less free acid, 
while in genuine marasmus it was absent. I recall a case of 
marked wasting as a result of ileocolitis seen with Prof. Bart- 
lett. We found the HC1. but slightly reduced and a good 
prognosis was given. The child promptly recovered under 
careful dieting. 

The etiology of marasmus is not always clear. In some 
infants there is undoubtedly a congenital feebleness of con- 
stitution which renders them incapable of conquering in the 
struggle for existence. Here heredity is an important factor, 
and we may find evidence of constitutional disease in the 
parents; on the other hand, they may be perfectly healthy. 
Extreme youth of the mother, and frequent pregnancy at 
short intervals is often noted on the maternal side of the his- 
tory. The surroundings play an important role. Crowded 
quarters and lack of fresh air and sunshine are strong con- 
tributing factors. The ordinary hospital ward is a most un- 
desirable quarter for infants convalescing from an acute ill- 
ness and unless promptly removed therefrom they soon show 
signs of failing nutrition. Some believe that infection of one 
infant from another, possibly through contaminated food, 
may take place, although there is no proof that specific bac- 
teria play a part in the etiology. 






CONSTITUTIONAL DISEASES. 627 

Symptomatology. — The infant may be delicate at birth, 
have difficulty in digesting its food even when breast-fed, and 
its progress follow a weight curve that is marked by progress- 
ive loss of weight interrupted by periods of temporary gain 
or standstill. More frequently the infant appears normal at 
birth and gets on perhaps as well as the average case up to 
from the third to sixth month, when as the result of some 
acute illness or what is more common, a change in the food, 
the nutrition gradually goes wrong. It is by no means nec- 
essary that the infant should have been on breast milk and 
that a change to artificial feeding be instituted in order to 
bring about this condition. A sudden change during artificial 
feeding to an ill-selected diet or the more gradual ill- 
effects from a diet that is unsuitable or insufficiently 
nourishing will accomplish the same results, especially 
when the environment is such as to favor marasmus. The 
emaciation progresses until the infant is reduced literally 
to skin and bones. The face has an old, wrinkled appear- 
ance, the eyes being sunken and the small triangular chin 
showing in marked contrast to the large head ; the chest 
is small and the ribs are plainly visible while the abdomen is 
large and distended. Through the thin abdominal wall the 
stomach and coils of dilated intestines can often be seen. The 
skin is pale and transparent. There is more or less intertrigo 
about the genitals and buttox and a few scattered boils are 
not uncommon. Anaemia is marked. The child presents the 
picture of distress and restless anxiety. 

On account of the adynamia these infants are inclined to 
develop (Edematous swelling of the face and extremities, which 
comes and goes. A temporary gain in weight may result from 
this oedema. The urine is normal under these circumstances. 
The temperature runs a subnormal course. An occasional rise 
to 99 or ioo° in the rectum occurs when acute indigestion 
intervenes, but this is only transitory. I have seen it running 
between 96 and 97 F. in the- morning (rectal) tor weeks 
with ultimate recoverv. 



628 



DISEASES OF CHILDREN. 



The stools vary in character. To all appearances they may 
be normal, excepting for an increased acidity. They tend to 
vary from day today in number, color and consistency. Usu- 
ally they are large and contain light colored curds with green- 
ish mucus. Alternate constipation and diarrhoea is frequently 



seen. 



The appetite is variable. Sometimes for a considerable 
period it is voracious and the child does not seem to get satis- 
fied. Then, again, it may be lost and there may be difficulty 




FIG. 56. — INFANT ONE YEAR OI v D WITH MARASMUS. 

in inducing the infant to take sufficient nourishment. In 
some instances acute inanition results from the refusal on the 
part of the infant to take its bottle. On account of the weak 
digestion and fermentation, colic is frequent and considerably 
complicates matters. 

The duration is difficult to foretell. The child may die 
suddenly from an intercurrent diarrhoea or broncho-pneu- 
monia ; gradual and persistent improvement may follow 
proper treatment or the case may drag on with exacerbations 
and ameliorations far into the second year. 



CONSTITUTIONAL DISEASES. 629 

The. prognosis is always grave, but it depends much upon 
the care the child can receive. Thousands of cases that die 
annually could be saved if they could be removed to more 
favorable surroundings and receive more skillful and consci- 
entious nursing. It is marvelous what persistent watching 
and self-sacrifice on the part of the mother or nurse will accom- 
plish in some cases with apparently the least hopeful outlook. 

Diagnosis. — The differentiation between marasmus and tu- 
berculosis is not always easy. It is said that the tuberculous 
infant is bright in appearance and. not so prostrated and apa- 
thetic as the marantic infant, but this is not a reliable sign. 
In tuberculosis we have continued fever as a more or less con- 
stant symptom ; at any rate, there will be distinct febrile 
movements at some time or another during the course of this 
disease. Besides, repeated careful examinations of the chest 
will ultimately reveal evidence of tuberculosis and we may 
also be able to detect enlarged mesenteric glands by palpa- 
tion of the abdomen. Persistent diarrhoea with pns in the 
stools and at times blood speaks strongly for tuberculosis. 

Malnutrition is a much commoner condition than maras- 
mus. It may be the result of premature or inherited feeble- 
ness of constitution, or follow after some acute illness, notably 
a gastro-intestinal affection. Again, malnutrition is a promi- 
nent symptom in tuberculosis, syphilis and severe rickets. 

Its most usual cause is improper feeding and unhygienic 
surroundings. As to the last named factors, they are just as 
likely to be encountered in well-to-do families as among the 
poorer classes, for here proprietary foods and close, over- 
heated nurseries come into play. In older children anaemia 
and malnutrition often date back to an attack of one of the 
infectious diseases or result from improper eating and school- 
hygiene. The diagnosis of simple malnutriton rests upon 
the exclusion of an organic disease or infection of which it 
might be only symptomatic. 

Treatment. — The regular weekly weighing of the infant is 
an absolute necessity and the only accurate guide by which 



630 DISEASES OF CHILDREN. 

we can judge of the progress of the case. The evening and 
morning temperature should be taken regularly, as this will 
indicate to us whether or not we must resort to artificial heat 
or extra clothing ; also whether the infant must be kept in 
bed or taken out in the fresh air. With a persistently sub- 
normal rectal temperature I have found it best to keep the 
child in bed, well clothed and a hot water bag at the feet. 
Such children should not be bathed but gently washed and 
then rubbed with warm olive oil. Very young infants who 
are too much exhausted by dressing and undressing can be 
wrapped in raw cotton. 

Of the highest importance is the diet. If the infant be 
breast fed we must determine by examination of the milk 
whether it be sufficient in amount and of proper chemical 
composition. If the milk be at fault and appropriate treat- 
ment applied to the mother does not improve the same, we 
must try a wet nurse. If the milk is simply deficient in 
quantity, mixed feeding should be instituted. 

As it is not always possible to obtain a wet nurse, we should 
bear in mind that in modifying the milk for a delicate or 
marantic infant it must be of a strength that would be suit- 
able for a much younger infant than the one in question. 

It is generally held that the proteids are the elements of 
the food that cause all the trouble in feeble digestion and 
there has been a tendency to cut them down to almost noth- 
ing while the fats are administered liberally. This is the 
mode of practice that my clinical experience has taught me 
to be erroneous. Some years ago I learned that infants who 
could not take milk, even when highly diluted, could often 
take it in fairly strong proportions if all the fat were removed. 
This is not true in every case, but there is a large class of in- 
fants who digest fat less satisfactorily than proteids and vtca 
versa. Some time ago a colleague consulted me concerning 
a case under his care, an apparently healthy infant of eight 
months, that would not gain weight, although the milk 
seemed to be properly modified. There were some signs of 



CONSTITUTIONAL DISEASES. 631 

gastric indigestion and I advised him to take the cream out 
of the food entirely. A month later he told me that the child 
began to gain immediately, but every time he tried to go back 
to the cream, the gain ceased. Holt has recently reported 
several cases in which serious toxic symptoms resulted from 
giving too much cream — the usual reason for giving so much 
fat being to overcome constipation. Edsall reported similar 
but less acute disturbances in older children, and here he 
demonstrated the presence of the lower fatty acids in the 
urine. 

The element of the food that is most easily assimilated and 
that is most required in these cases to maintain the body heat 
and keep the machinery going is the sugar, or carbohydrate. 
That is why condensed milk, which contains a low fat and 
proteid percentage and a high carbohydrate percentage often 
agrees after the physician has racked his brain in the at- 
tempt to find a suitable milk-formula. It is eminently bet- 
ter, however, to apply this principle in modifying the milk 
than to have the infant put on such an inferior article. 

Milk sugar is preferable to cane sugar in these cases for sev- 
eral reasons. In the first place, it is more easily assimilated, and 
can be given in larger quantities. Secondly, it does not so read- 
ily undergo fermentation in the intestinal tract, but when there 
is a tendency to diarrhoea it may aggravate this condition. 
Cane sugar and even starch should not be depended upon as 
a food in early infancy. Cane sugar may produce untoward 
effects in certain infants, such as gastric irritability, vomiting 
and colic. I have seen cases in which every attempt to sub- 
stitute granulated sugar for lactose was followed by vomiting. 

The chief function of starch in early infancy is to render 
the casein of the milk more easy of digestion. This is purely 
a mechanical effect. For this purpose we dilute the milk 
with barley-water. When milk is not borne well it is a good 
plan to interpolate several bottles of mutton broth made with 
rice or barley in the feeding schedule. 

I have not had happy results from the predigestion of starch 



632 DISEASES OF CHILDREN. 

solutions with malt diastase. On the other hand, dextrinized 
starch is well born in many instances. Baked flour, or a 
water-cracker rolled into a powder and then boiled with suf- 
ficient water to make a thin pap and a little milk and sugar 
added is well borne by infants of a year or older. 

For the class of infants who do not digest the proteids of 
milk well, Edsall has suggested bean flour, on account of its 
high proteid percentage. He used it in a number of marantic 
cases in a solution that was subsequently dextrinized, and re- 
ports good results. Dr. S. W. Sappington experimented with 
this food at the Children's Homoeopathic Hospital, but his re- 
sults were not encouraging. The use of peptonized milk does 
not give the results expected of it. It is not so much faulty 
digestion as faulty assimilation that really lies at the bottom 
of the trouble. The good results obtained from Peptogenic 
Milk Powder are, to my mind, due more to the milk sugar 
and bicarbonate of soda it contains than to the pancreatic 
extract. 

Stimulation is at times called for. A few drops of brandy, 
well diluted, given during periods of great depression, has 
seemed helpful. Panopetone may also be tried. 

On account of the anaemia, freshly prepared beef juice 
(diluted) should be given in small quantities daily (^ss to gj). 
Diarrhoea would temporarily contraindicate its use. We 
know that even human milk contains insufficient iron to sup- 
ply the requirements of the organism after a certain period, 
as has been pointed out by Bunge, and that the infant actu- 
ally draws from the store of iron present in its tissues at birth 
to sustain the haemoglobin percentage of the blood. Conse- 
quently anaemia develops if milk is continued as the sole food 
beyond a certain time, and more markedly in subnormal than 
in normal infants. 

Instead of giving the usual quantity of food, it may be 
necessary to use a smaller amount at shorter intervals before 
the digestive tract will tolerate even a weak milk mixture. 
This, like every other question with the cases, must be ascer- 
tained by trial and experimentation. 



CONSTITUTIONAL DISEASES. 633 

The question of the use of alkalies in the food often arises. 
When there is vomiting of curds or the passage of curds in 
the stools, sodium carbonate should be added to the milk in 
small quantities (2 to 3 grs. to the bottle). This will prevent 
the formation of the tough curds of paracasein chlorid and 
allow the more delicate curds of casein to enter the intestinal 
tract where they will be digested by the pancreatic juice. If 
there are loose, acid stools and much gas, lime water is pre- 
ferable. I have occasionally seen beneficial results from the 
administration of a few drops of dilute hydrochloric acid in 
water, half an hour after nursing, where there was a deficiency 
of the gastric secretion. The bicarbonate of soda, aside from 
its action upon the casein, also appears to exert some influence 
over the acid intoxication that plays so important a role in 
many of these cases. 

Orange juice, on account of its beneficial effects in rickets 
and scurvy, may be used with advantage, especially when 
there is constipation and when the infant has been taking 
sterilized milk for some time. When the stools become highly 
acid and irritating the carbohydrates must be cut down and 
proteids (egg albumin, meat broth) increased, while in offen- 
sive and alkaline stools the carbohydrates must be increased 
and proteids cut down. 

. In looking over the list of remedies recommended in de- 
praved states of nutrition, the deep acting constitutional ones 
stand in the foreground. Much benefit is derived, however, 
from paying attention to the acute symptoms as they arise 
and prescribing such remedies as Nnx vomica, Podophyllum, 
China, etc., intercurrently. 

The calcareas seem indicated in the majority of cases, es- 
pecially Calc. phos. Iodine is strongly related to emaciation 
and glandular atrophy, and the iodides are often indicated, 
especially the Iodide of Arse?iic, when there is great prostra- 
tion, nervous irritability and restlessness ; tendency to diar- 
rhoea ; dropsical swelling of the face and extremities. 

Sulphur has many of the symptoms of marasmus, and it 
4i 






634 DISEASES OF CHILDREN. 



suits especially the cases with cutaneous eruptions ; intertrigo ; 
irritating stools and urine. Mevcurius naturally suggests 
itself where there is a suspicion of syphilis. 

Lycopodium and Natrum muriaticum are important in mal- 
nutrition and emaciation, and will suggest themselves by 
their characteristic symptoms. 



CHAPTER XIX. 

ACUTE INFECTIOUS DISEASES. 
EXANTHEMATA. 

The exanthemata constitute a group of acute infectious 
fevers belonging to the period of childhood, occurring epi- 
demically, and characterized by the eruption of an exanthem 
upon the surface of the body. To this class belong measles, 
rubella and scarlet fever. Although a specific causative 
micro-organism has not yet been demonstrated in any one of 
these diseases, still there is no doubt as to their infectious- 
ness, and it is quite likely, as Welch {American Text- Book 
of Practice) states, that they depend upon another form of 
micro-organism, not a bacterium, for the demonstration and 
study of which we are at present not fully equipped. In the 
light of the most recent investigations it appears that a num- 
ber of the infectious diseases of unknown origin are due to a 
protozoon and not to a bacterium. 

MEASLES, RUBEOLA. 

Measles is one of the commonest of all acute diseases of 
childhood and there appears to be a universal susceptibility to 
the disease as few people go through life without having had 
it either in childhood or in later life. A child that has been 
exposed to measles rarely escapes contracting the same. 
It occurs preferably in epidemics during those months 
favoring catarrhal affections; spring epidemics are usually 
the severest. One attack affords immunity against another. 
The period of incubation is from ten days to two weeks 
in the average of cases. Contagiousness is present from 
the time of invasion, being most pronounced at the height 
of the catarrhal manifestations and fever. It rapidly van- 



636 DISEASES OF CHILDREN. 

ishes with the disappearance of the eruption, and at the 
end of the third week there remains little or no danger of 
contagion. The contagion is usually spread by close contact, 
and is seldom conveyed by means of intermediate objects or 
a third person, it also being readily destroyed by thorough 
airing and fumigation. Measles, however, is more readily 
disseminated than scarlet fever or diphtheria and an epidemic 
is more likely to attain wide-spread proportions than in the 
latter diseases. 

Symptomatology. — The course of a typical case of measles 
is in three stages. These are characteristic to the exanthe- 
mata in general, but most clearly defined in measles. They 
are: the stadium prodromorum, or prodromal stage; the 
stadium eruptionis, or stage of eruption, and the stadium 
florescenticE, or stage of desquamation. 

The first stage is characterized by fever and catarrhal 
symptoms of gradual onset, showing themselves as a cold in 
the head, with bloodshot eyes and lachrymation, accompanied 
by chilliness and headache. The catarrhal process extends to 
the larynx and trachea, resulting in the characteristic hoarse 
cough. On the third day single, lentil-sized red spots are seen 
upon the roof of the mouth and soft palate, frequently 
being observed twenty-four hours before the eruption upon 
the skin makes its appearance. Koplik's sign appears 
even earlier and is more truly pathognomonic of measles in 
the period of invasion. He describes this buccal enanthem 
as follows : "If we look into the mouth at this period we see 
in a strong light the usual redness of the fauces, perhaps not 
in all cases a few red spots on the soft palate. On the mu- 
cous membrane lining the cheeks and lips (buccal mucous 
membrane) we see a distinct and pathognomonic eruption. 
This consists of small irregular spots of a bright-red color ; 
in the centre of each spot is the interesting sign to which I 
wish to call attention. In strong daylight we see a most 
minute bluish-white speck. These minute bluish-white 
specks in the centre of a reddish spot are absolutely pathog- 



ACUTE INFECTIOUS DISEASES. 637 

nomonic of beginning- measles"* (N. Y. Med. Record, April 
9, 1898). This sign is present in all cases twenty-four hours 
before the skin eruption, and often three days preceding it. 

(KOPLIK.) 

The second stage begins on the fourth or fifth day. The 
eruption makes its appearance first on the face in the majority 
of cases, accompanied by increased fever. Thence it spreads 
over the entire body surface, the eruption being completed in 
two to three days. Its spread, however, may be irregular and 
interrupted, and desquamation may occur on one portion of 
the body while the eruption is appearing on another. The 
exanthem is the product of a superficial dermatitis, with pap- 
ule formation through round-cell infiltration about the papillae, 
the cutaneous glands and small blood-vessels. There may 
be also oedema of the skin accompanying the inflammatory 
process ; this is most prominently seen upon the face. The 
eruption proper consists of numerous, roundish, lentil-sized 
red spots, slightly raised above the level of the surrounding 
skin, or containing in their centre a little papule. Where 
they are very numerous they coalesce, forming crescentic 
plaques, or they may fuse entirely into large, spotted areas 
{morbilli confluentes). Cases in which the hyperaemia is so 
great as to cause cutaneous haemorrhages are described as 
morbilli petechialis or black measles; in these cases the erup- 
tion assumes a dark color from petechial haemorrhages. Pe- 
techial measles is by no means always a more serious condi- 
tion than the ordinary form ; in fact, I have encountered a 
number of cases running a rather mild course, in which the 
eruption assumed this haemorrhagic type. 

A distinctive difference between the eruption of measles 
and that of scarlet fever is its behavior to point-pressure : 
"The spots disappear by finger-pressure, but the redness soon 
reappears from the centre toward the periphery " (Hartmann, 
Die Kinderkraiikh., Leipzig, 1852) in measles, while in scar- 

* The first article upon this subject appeared in . trchives of Pediatrics 

December, icSc^b. 



638 DISEASES OF CHILDREN. 

let fever the redness reappears from the periphery toward the 
centre. Dr. Hartmann, however, offered no explanation for 
this phenomenon, which I think is easily understood from a 
close study of the eruption. In measles we have papules sur- 
rounded by areas of erythema, and by applying firm pressure 
to a patch of eruption with the finger-point we force the blood 
from the erythematous area surrounding the papule, but do 
not completely deplete the hypersemic papillae forming the 
papule, which recovers itself quickly through its great vas- 
cularity, for which reason the redness seems to reappear or 
even persist in the centre of the compressed skin area. In 
scarlet fever, on the other hand we have either a diffuse hy- 
peraemia or a fine, closely-aggregated miliary eruption, which 
behaves like the erythema surrounding the measle papule; 
in other words, the area of skin pressed upon is completely 
depleted, there being no central papule, and the redness reap- 
pears from the periphery toward the centre, as the greatest 
amount of pressure has been brought to bear upon the centre 
of the area, and consequently the greatest amount of depletion. 

In young children convulsions sometimes occur at the time 
the eruption makes its appearance. The catarrhal symptoms 
reach their acme, and broncho-pneumonia and troublesome 
diarrhoea are to be feared during this period. Catarrhal in- 
flammation of the conjunctiva, nose, pharynx, larynx, trachea 
and bronchi are so closely associated with the course of an 
attack of measles that they are really to be looked upon as 
characteristic lesions of the disease. The strong tendency 
for the process to extend from the bronchi into the bronchi- 
oles and air-vesicles is one of the most dangerous features of 
measles, and almost every fatal case is directly due to pneu- 
monia or exhibits signs of the disease. 

The inflammation of the pharynx and larynx may become 
croupous, and suppurative otitis media may appear as a* com- 
plication at this stage, although neither of these conditions 
are as common to measles as to scarlet fever. 

In the alimentary tract a similar catarrhal condition may 



ACUTE INFECTIOUS DISEASES. 



639 



become established, showing itself as anorexia, vomiting, 
heavily-coated tongue with enlarged marginal papillae, and 
diarrhoea. The latter, when once established, is liable to 
continue throughout convalescence. 

At the end of about four days the eruption begins to fade, 
disappearing first in those localities where it was primarily 
seen. In mild cases it has already become much paler at the 
end of twenty-four hours, and it may disappear entirely from 
one part while another part is being invaded. With the fad- 
ing of the rash desquamation takes place in the nature of fine, 
branny scales, first noticed upon 
the face and neck. It is com- 
pleted in a week in the average 
case, seldom continuing for a 
much longer period. 

The eruptive period is pro- 
longed in those cases in which 
it becomes haemorrhagic. Here 
it assumes a deep-red color, 
gradually becoming darker 
(ecchymotic) and slowly fading 
out as the blood-pigment is 
absorbed. Again, the eruption 
may suddenly disappear, indi- 
cating great adynamia and 
heart failure. The character- 
istic " measly odor " is most prominent at this time, although 
it begins to develop during the height of the fever and 
catarrhal manifestations. 

The temperature is not high in mild cases, being highest 
during the eruptive period, when it may reach 104 F. for 
a short time. In the average case there is an abrupt rise at 
the point of invasion — about 102. 5 F. (initial fever). It 
soon falls to a lower period, not rising again until the fourth 
or fifth day, when the eruption makes its appearance.- At 
this stage it may reach 104 F. and higher. In a day or two 



104° 








1 — — 


t 










































































It 
















1 A 
















\f- 


; 1 


















n 














' 1 














\ 


■\ . 








' 




— 


i 
































































: 1 ' 
















\~ 
















V 






























\ 
















\ 
















i\ 


































1 




































: 




















































— ■ 


1 






















— 




























































































| 


































DayqfDis 


/ 


z 


J 


¥ 


S 


6 


7 r 



FIG. 57.- 

FROM 



-TEMPERATURE CHART 
A CASE OF MEASLES. 



640 DISEASES OF CHILDREN. 

it drops by crisis, unless it is sustained by a complicating 
broncho-pneumonia, etc. 

Among the many complications liable to arise during the 
course of measles or appear as sequelae, the following are the 
most important and most frequent in occurrence : Broncho- 
pneumonia (children under three years) ; lobar pneumonia, 
pleuro-pneumonia and empyema, (three years and over); mem- 
branous croup ; putrid sore throat ; noma ; entero-colitis ; 
conjunctivitis and keratitis ; otitis media. 

The frequency with which tuberculosis develops after 
measles is noteworthy. In some instances latent scrofulous 
lesions are stirred up by the attack, while in others it appears 
that primary infection occurs directly upon the subacute 
pneumonic process lingering after convalescence. The con- 
gestion of the bronchial glands which accompanies measles 
renders them more liable to infection with the tubercle ba- 
cillus. According to Osier, tuberculosis is the most important 
sequela — either an involvement of the bronchial glands, a 
miliary tuberculosis, or a tuberculous broncho-pneumonia. 
Homoeopathic authorities are, however, not inclined to take 
such a grave view in cases of measles under homoeopathic 
treatment. 

The blood in measles shows a trifling degree of anaemia 
and instead of leucocytosis there is an actual leucopenia in 
uncomplicated cases (Combe). The urine may give the diazo- 
reaction, but albuminuria is rare. 

Treatment. — The child should be put to bed in a well- 
ventilated, moderately-darkened room as soon as the disease 
is suspected, maintaining a temperature of 65 ° F. when 
possible. It is unnecessary to render the room dark and 
cheerless, an effectual shielding of the eyes from direct bright 
light being all-sufficient. The child should be kept in bed 
until every trace of the rash has disappeared, which usually 
takes place about five or six days after its first appearance. 
The removal of the branny scales of epidermis is greatly fa- 
cilitated by rubbing the child with olive oil, followed by a 



ACUTE INFECTIOUS DISEASES. 641 

sponging with tepid water and Castile soap. This measure 
should be employed for several evenings in succession after 
the febrile symptoms have abated. During the febrile period 
there is no objection to the cleansing sponge-bath of tepid 
water. If conjunctivitis be present the eyes should be flushed 
several times daily with a 2 per cent. Boric-acid solution. 

In cases in which the rash is tardy in coming out, or in 
which there is a recession of the same, a warm bath or pack 
is of great service. With recession of the rash the condition 
often becomes grave. When due to cardiac failure stimula- 
tion is indicated, and a hot-mustard bath is a valuable ad- 
juvant when serious congestion of internal organs (broncho- 
pneumonia, meningitis, etc.) exists as a complication. 

In dieting cases of measles we must bear in mind the ten- 
dency to diarrhoeal conditions, just as in scarlet fever we must 
anticipate nephritis. 

During convalescence the diet should be highly nutritious, 
consisting largely of milk, eggs, fresh vegetables, lamb-chops 
etc. If a tendency to tuberculosis exists, cod-liver oil may be 
added with advantage. A week should elapse before the 
child is permitted to leave the house, and by the end of the 
third week from the commencement of the disease he may be 
allowed to commingle with other children, as the infectious 
period has passed over by that time. 

The following remedies will be found to cover the usual 
cases : 

Aconite corresponds to all of the early symptoms of the 
average cases of measles, and when given in time will so con- 
trol the disease that it frequently becomes unnecessary to 
give any other remedy during its entire course. It is hardly 
necessary here to give its indications. In infants, however, 
when the fever is high and nervous symptoms are prominent, 
I more frequently find Belladonna useful. 

Apis. — Confluent eruption, with pronounced oedema cf the 
skin ; oedematous swelling of the throat ; cerebral complica- 
tions. 



642 DISEASES OF CHILDREN. 

Arsenicum is indicated in those adynamic cases in which 
there is pronounced prostration ; scanty rash ; anxiety and 
restlessness ; pneumonia. 

Bryonia. — Cases calling for Bryonia are characterized by 
a predominance of catarrhal symptoms from the very begin- 
ning with tendency to extend to the finer bronchial tubes and 
involve the pulmonary parenchyma. The rash is slow in 
coming out, but, when once established, it is usually abun- 
dant and characteristic. The accompanying symptoms are 
dry, painful cough ; great lassitude and irritability ; anorexia, 
with thirst for large quantities of water ; constipation, etc. 
Bryonia is looked upon somewhat as a specific to bring out 
the rash, but any well-selected remedy will accomplish the 
same result, notably Pulsatilla and Gelsemiinn. 

Camphora. — u In those dangerous cases where the face 
grows pale and the skin cold, assuming a bluish, purple color, 
with utter prostration and spasmodic stiffness of the body." 
(C. G. R.) 

Coffea is a valuable remedy for the short, dry, teasing cough 
of measles, frequently becoming a most distressing complaint 
in nervous, delicate children. 

Euphrasia. — Profuse corroding discharge from the eyes, 
with profuse, bland, nasal discharge {Allium cepa has the op- 
posite condition). 

Gelsemium. — "After Aconite, great deal of coryza ; drowsy, 
with fever heat ; no thirst. When the eruption turns livid, 
with cerebral symptoms" (C. G. R.). 

Kali bichromicum is indicated in measles when there is a 
deep, loud cough, with expectoration of stringy, yellowish 
mucus ; intense conjunctivitis, sometimes going on to keratitis 
and ulceration; stitches in the ears, extending into the 
head and neck ; watery diarrhoea, with tenesmus ; ulcerated 
sore throat. Even when the symptoms are not so severe or 
characteristic as above stated, this remedy is frequently of 
great value, especially when Bryonia does not control the 
bronchitis as promptly as it should. It is followed well by 
Pulsatilla. 



ACUTE INFECTIOUS DISEASES. 64-3 

Lachesis. — Livid eruption, countenance almost black, 
tongue coated dark brown, sordes on the teeth, inability to 
protrude tongue (J. F. Miller). 

Mercurius is indicated where gastro-intestinal symptoms 
predominate. The tongue is heavily coated, showing the 
imprints of the teeth ; breath very offensive ; diarrhoea of 
slimy stools, with tenesmus. Also bronchitis, with loose, 
barking cough and no expectoration ; offensive sweats ; diph- 
theritic angina. 

Pulsatilla may be indicated early, although its sphere of 
usefulness lies mostly in the clearing up of the cough and 
catarrhal symptoms lingering after measles. It is followed 
well by Hepar. 

Veratrum viride. — u During febrile stage, especially if pul- 
monary congestion is impending; red streak down centre of 
tongue; convulsions before eruption" (C. G. R.). 

Other remedies which may be called for upon special indi- 
cations are : 

Belladonna. — May be indicated early, but less frequently 
than Aconite in mild cases. Nervous symptoms predominate^ 
and convulsions occur at the eruptive stage. 

Carbo veg. — Persistent hoarseness remaining after measles. 

Drosera. — Cough occurring in paroxysms in the afternoon, 
spasmodic and attended with bloody or purulent expectoration. 

Hepar and Spongia may be required when the cough be- 
comes croupy. 

Phosphorus and Antimon. tart , in those cases in which 
broncho-pneumonia predominates. 

Sulphur. — Either during the first stage, when the eruption 
is tardy, or for the sequelae, such as chronic coughs, originat- 
ing in the remnants of partial pneumonia; chronic diarrhoea; 
hardness of hearing and chronic ear discharges (C. G. R.). 

SCARLET FEVER. 

Scarlet fever is a highly contagious, infectious disease of 
childhood, characterized by fever, angina and a diffuse scarlet 



644 DISEASES OF CHILDREN. 

eruption, followed by desquamation. It is endemic in all 
large cities, often breaking out in epidemics. The greatest 
degree of susceptibility exists between the ages of two and 
six; infants usually escape, especially those nursing at the 
breast, while in children nearing puberty the susceptibility 
gradually decreases. One attack gives immunity to a second, 
as a rule. Epidemics are most prevalent during the fall and 
winter months. 

While scarlet fever is not as infectious as measles, its spread 
being slower and less extensive than that of measles in com- 
munities or non-isolated quarters harboring cases, still its con- 
tagiosum vivum possesses much greater tenacity to life, and 
is much more readily carried from one location to another by 
means of a third person or by contaminated objects. It re- 
tains its vitality for months, and requires active germicidal 
measures for the successful disinfection of infected localities 
and articles of dress, bedding, etc. 

The period of contagiousness lasts about six weeks, begin- 
ning with the invasion of the disease, reaching its height during 
the febrile period and persisting until desquamation is com- 
plete. The source of infection lies in the catarrhal discharges, 
the scales of epidermis, and probably also in the excreta. The 
contagion may persist in the expectoration or nasal secretion 
even after the stage of desquamation. 

The exact nature of the causative agent of scarlet fever still 
remains obscure. Streptococci are found in the blood in a 
certain percentage of cases, but they are rather to be looked 
upon in the light of a secondary infection than as the primary 
cause of the disease. Hektoen {Jour. Amer. Med. Ass., March, 
1904) isolated streptococci from twelve out of a hundred cases. 
They occur with relatively greater frequency in the more 
severe and protracted cases, but they may be absent in some 
of the fatal cases. Mallory {Jour, of Med. Research, Jan., 
1904) claims to have demonstrated certain bodies in the skin 
of fout cases of scarlet fever, which he looks upon to be one 
of the stages in the development of a protozoon. The period 






ACUTE INFECTIOUS DISEASES. 645 

of incubation is short, usually less than a week, and in many 
cases only one to two days. 

Symptomatology. — The course of a typical case of scarlet 
fever may be divided into the -stage of invasion, stage of erup- 
tion and stage qf desquamation. Prodromata are rare, the in- 
vasion being abrupt, with repeated chills, followed by high 
fever, headache, prostration and vomiting, together with sore 
throat. Such a combination of symptoms occurring in a child 
should always lead one to suspect scarlet fever. The temper- 
ature may rise very rapidly to a high point, reaching 104 F. 
and over ; in mild cases, however, it may rise but inconsider- 
ably. The pulse likewise is affected in a characteristic manner, 
attaining a rapidity of one hundred and twenty to one hun- 
dred and forty beats per minute quite early in the attack. 
The throat is highly inflamed, a diffuse erythematous blush 
covering the tonsils, pharynx and soft palate. Later on, 
diphtheritic patches are liable to appear. 

Within from twelve to thirty-six hours from the beginning 
of the fever the eruption makes its appearance, first showing 
about the neck and chest, whence it rapidly spreads over the 
entire body, this being accomplished within twenty-four to 
thirty-six hours, or in even a shorter period of time. The 
eruption appears most intense on the neck, over the extensor 
muscles, about the joints, and on the dorsum of the hands and 
feet. A peculiar pallor about the mouth is frequently seen, 
producing a striking contrast with the flushed cheeks, and 
giving rise to the characteristic "white line'' of the disease. 
The eruption is due to intense hyperaemia of the skin, accom- 
panied by exudation of round cells into the rete Malpighii 
and serous exudation, the process ending in death of the epi- 
dermis, with desquamation of variously-sized scales and flakes. 
The predominating feature in the pathology of the cutaneous 
manifestations is vascular paralysis. When typical, the rash 
consists of numerous, closely-aggregated red points, the size 
of a pin-head, evenly distributed over the entire body, giving 
it a bright, scarlet color. The eruptive points may be but 



646 DISEASES OF CHILDREN. 

slightly red in the beginning, later assuming the bright, scar- 
let hue. The rash is more frequently a dull red than scarlet* 
and the general effect is produced by the erythema associated 
with puncta, fine vesicles and more or less goose-flesh. The 
punctate spots are the result of inflammation around the hair 
follicles, and they may become large enough to impart to the 
skin a distinctly rough feel. The points may be flat or ele- 
vated, round or lentil-shaped, and with increasing hypersemia 
they become confluent, the skin becoming turgescent and 
tense. The swelling is most marked about the face and eyes 
in these cases {scarlatina Icevigata). This is the variety for 
which Hahnemann recommended Belladonna as both prophy- 
lactic and curative, while for scarlatina miliaris, a variety in 
which there are minute papules interspersed with fine vesicles 
filled with a turbid serum, he recommended Aconite (HarT- 
mann, Kinder krankheiteri), considering it a special variety of 
scarlet fever. Another deviation from the usual eruption is 
the appearance of roseola-spots of various sizes and shapes, 
separated by pale areas of skin {scarlatina variegatd). In 
some cases the rash does not become general, often being ab- 
sent from the face in mild cases. It may be extremely faint 
in color, or assume a deep purplish hue, or become hemor- 
rhagic. 

At the height of the eruption the skin is burning hot to 
the touch, and the patient complains of burning, stinging 
and itching ; at this time, also, all other symptoms are most 
intense. 

Pressure with the finger causes momentary disappearance 
of the rash, which reappears from the periphery toward the 
center, differing in this respect from the rash of measles. 
In cases marked by prostration the peripheral circulation is 
so poor that the rash only slowly reappears after having been 
obliterated by pressure. This is a valuable prognostic sign. 

The temperature curve of scarlet fever is one of abrupt 
onset, the fever running high with very little remission during 
the first three or four days and then gradually subsiding by 



ACUTE INFECTIOUS DISEASES. 



64-7 



lysis so that at the end of a week the temperature is again 
normal. 

The tongue is thickly coated white ; the edges, however, 
remaining red. In the course of a few days the coating is 
shed, leaving the red and swollen papillae exposed, with the 
resulting characteristic appearance described as " strawberry- 
tongue." Enlargement of the papillae of the tongue is such 
a constant symptom of scarlet fever that it becomes a most 
valuable diagnostic sign. Indeed, McCollom, of Boston, looks 
upon this symptom when occurring in association with fever 
and sore throat as pathogno- 
monic of scarlet fever, irre- 
spective of the presence of 
a rash. In mild cases, how- 
ever, the enlargement of the 
papillae may fail to develop. 

Should the throat become 
seriously affected at this 
time, patches of membrane 
will be seen upon the tonsils 
which may spread to the 
soft palate and adjacent 
parts. This complication is 
usually due to streptococci, 
true diphtheria being rare 
during the course of scarlet 
fever, and, when associated 

with the same, occurring as a sequela rather than as a com- 
plication. 

Otitis is a frequent complication occurring at the height of 
the disease, the result of an extension of infection from the 
angina. It usually terminates in suppuration, and is one of 
the commonest causes of deafness in children. When occur- 
ring during convalescence its advent is more readily antici- 
pated, as there is recurrence of fever, with distinct earache 
and impairment of hearing. 





1 






■ 










i 




















; 




















































!04° 








































































































































































































































































































































































































































































. 








































d 


A 


























v 


_\ 




























ij 
























































~ 




























r 




























X 


























^_ 


























c 


















































98° 












































































































































































































































































DayofDis 


/ 


X 


i 


¥ 


f 


t 




1 i 


' 9 



FIG. 58.— TEMPERATURE CHART FROM 
A CASE OF SCARLET FEVER. 



648 DISEASES OF CHILDREN. 

Parotitis and cellulitis of the neck sometimes accompany 
the septic process in the throat. The termination of such a 
process is usually in suppuration. Likewise the tonsils and 
lymphatic glands of the neck may share in the suppurating 
process, rendering the prognosis most unfavorable. 

Synovitis of the larger joints is prevalent during some epi- 
demics. It develops between the first and second weeks. 
The duration is short, never ending in suppuration. Beside 
this condition, an attack of acute articular rheumatism is fre- 
quently invited in individuals of the rheumatic diathesis, oc- 
curring as a complication of the scarlet fever either during 
the eruptive stage or during convalescence. 

The blood shows a well-marked leucocytosis, the poly- 
nuclears predominating. The more intense the infection the 
higher the leucocytosis. In asthenic cases, however, there 
may be a failure on the part of the organism to react and in 
such cases a low leucocyte count offers a grave prognosis. In 
such cases the eosinophiles may be decreased or absent 
(Da Costa). 

The lymphatic glands, both the subcutaneous as well as the 
lymphatic structures of the viscera are involved. There is 
more or less general adenopathy, the cervical, inguinal and 
axillary glands being especially affected. 

Postscarlatinal nephritis is one of the most constant and 
most important complications of scarlet fever, occurring 
typically during the third week. Pathologically, it is an 
acute, diffuse, productive nephritis. It is a more serious con- 
dition than the simple acute degeneration or acute exudative 
nephritis which may. occur early in the course of the fever, 
just as in any other acute infectious disease. There is scanty 
urine and general dropsy, and suppression of urine and acute 
urcemia may supervene. Although the kidney is much dam- 
aged at the time, still a marvellous degree of regeneration 
may set in and the child shows a fair chance of ' : growing 
out " of the disease, so to speak, under careful treatment. 

Desquamation begins shortly after the rash has faded — about 



ACUTE INFECTIOUS DISEASES. 



649 



the end of the first week. It begins in the localities in which 
the rash first appeared, showing itself as scales of varying 
size about the neck and chest. Gradually the entire trunk is 
involved in the process, desquamation being completed here 
long before the fingers and toes have shed their dead epi- 
dermis. In these parts, especially where the skin is thick, the 
peeling process is slow, and large pieces of skin, sometimes 
complete casts of the fingers, are detached in the u moult- 
ing" process. In cases where desquamation is slight, it may 
be found characteristically by about the tenth day at the tips 
of the fingers. A separation of the epidermis at the edge of 
the nail-bed, producing the line of " subungual cleavage," is 
a characteristic phenomenon. 

The prognosis depends to a great extent upon the character 
of the epidemic ; the general health of the child before the 
attack ; the height of the fever, and the severity of the at- 
tending complications. As a rule, the disease is more liable 
to prove fatal if the child is very young, especially when seri- 
ous throat implication, nasal diphtheria, diarrhoea or otitis 
are associated. The degree of toxaemia and the state of the 
peripheral circulation are important prognostic indications. A 
livid, sluggish rash or recession of the rash, indicating fail- 
ing circulation, are unfavorable signs. Cases marked by sud- 
den onset with excessively high fever offer a grave prognosis 
on account of the high degree of toxaemia they present. Some 
cases prove fatal within the first twenty-four hours before the 
rash appears — "malignant scarlet-fever." 

Among the later dangers are especially to be feared ne- 
phritis, which displays a tendency to develop particularly in 
cases in which cutaneous manifestations are mild, probably 
because the scarlatinal toxines are more actively excreted 
through the kidneys than through the skin in these cases. 
Should ursemic convulsions supervene, either death or cerebral 
haemorrhage with resulting hemiplegia, etc., may result. 
Otitis always brings with it danger of cerebral abscess. The 
patient is also liable to develop true diphtheria at this time. 
42 



650 DISEASES OF CHILDREN. 

Convalescence is usually protracted owing to anaemia, 
chronic otorrhcea and nasal catarrh, hypertrophied tonsils, 
post-scarlatinal nephritis. 

Diagnosis. — Scarlet fever differs from measles in the abrupt- 
ness of its onset, the absence of Koplik's sign and prominent 
catarrhal symptoms, and the characteristic appearance and 
behavior of the eruption alluded to in the symptomatology of 
both affections. The scaling in scarlatina is also different 
from that observed in measles. From rubella it is dis- 
tinguished by the sudden onset and high fever with pro- 
nounced sore throat, by the characteristic appearance of the 
tongue, and by the occurrence of desquamation. Symptomatic 
rashes can usually be traced to the partaking of certain arti- 
cles of food or the administration of certain medicines, or to 
septic- or auto-intoxication. The rash is of short duration, sore 
throat is absent, and in the absence of gastric derangement 
the temperature is normal. Many of the infectious fevers are 
at times accompanied by an erythematous rash, causing con- 
siderable confusion as to the true nature of the case. All 
doubtful cases, however, followed by the typical desquamation 
and associated with albuminuria, are to be looked upon as 
scarlatina. 

The history of exposure to infection is an important datum 
in atypical and incomplete cases, as is also the appearance of 
the tongue and the presence of general adenopathy. The 
presence alone of scaling is not a proof that the case is one of 
scarlet fever, and scaling may be more pronounced in certain 
cases of desquamative scarlatiniform erythema than in ordi- 
nary scarlet fever. The time of onset, mode of progress and 
its persistence are of more importance than the mere presence 
of scaling (Schamberg). On the other hand, in a case of 
scarlet fever with well-developed rash and subsequent marked 
desquamation, the associated conditions, namely, fever, pros- 
tration, sore throat and adenopathy, are more pronounced 
than in the scarlatiniform erythemata. 

Treatment. — With the occurrence of suspicious symptoms 



ACUTE INFECTIOUS DISEASES. 651 

the patient should be isolated immediately. From this time 
on until desquamation is completed, and, if practicable, until 
all catarrhal discharges have been controlled, the child should 
be kept away from others to whom or through whom it may 
convey the contagion. Six weeks from the beginning of the 
attack is usually a sufficiently long period of quarantine ; but, 
just as with the classical ten days of the lying-in period, there 
is liability to variation in either direction. 

The bedroom should be freely ventilated, and all unneces- 
sary articles of furniture and hangings should be removed, 
but not after they have been exposed to the contagion, unless 
they can be immediately disinfected. A sheet wrung out of 
a 2 per cent, solution of Carbolic acid and hung in front of 
the door adds to the completeness of the isolation. All 
kitchen utensils, etc., used by the patient should be immersed 
in a 4 per cent, solution of Carbolic acid or Formaldehyde for 
an hour before being removed from the room. The)' should 
then be scalded, or, still better, boiled for a quarter of an hour. 
The nurse and the attending physician should protect their 
outer clothing by donning a long, linen coat on entering the 
sick room, and disinfect their hands before leaving the room. 
All sheets, rags, articles of clothing and furniture that can be 
dispensed with are best burned. For disinfection of the room 
after its vacation by the patient there is nothing equal to 
Formaldehyde gas generated in the Schering lamp from pas- 
tilles. If Sulphur be used, one pound must be burned for 
each hundred cubic feet of room space; at the same time 
steam should be generated, the room of course being hermet- 
ically sealed during the operation. It is always wise to pre- 
cede the fumigation by a thorough mopping cf the floors with 
a i to 2,000 bichloride solution, allowing it to dry in situ. If 
the walls are papered, they should be scraped down and re- 
papered. 

During the occupation of the room by the patient the spray- 
ing of hydrogen dioxid with an atomizer greatly aids in keep- 
ing the air pure. If the patient suffers much from angina or 



652 DISEASES OF CHILDREN. 

laryngitis it will prove advantageous to generate steam, at the 
same time placing dishes of slaked lime about the room. 

u The terrible burning and itching of the skin is best re- 
lieved by rubbing the body all over with bacon, olive oil or 
cocoa-butter, once or twice a day ; always if the skin is dry,, 
glands swollen, and there is a scrofulous diathesis." (C. G. R.) 
I would object to the use of carbolized oil or other powerful 
antiseptic applications to the skin at this time, its action 
being necessarily injurious and its efficacy in destroying con- 
tagion questionable. The inunction of fats not only relieves 
the itching and burning of the skin, but it also acts as a 
sedative and at times reduces the fever. 

In case of high fever a sponge-bath of tepid water and 
alcohol (one part of alcohol to three of water) is of great 
service. In the advent of anasarca or suppression of urine a 
warm pack should be used. (See Treatment of Acute 
Nephritis, p. 371.) For the angina, a spray of alcohol one 
part, glycerin one part and water four parts, may be used sev- 
eral times daily. Likewise, the nose should be kept scrupu- 
lously clean by means of douches of a norma] saline solution 
or Dobell's solution. These simple measures may prevent 
ulceration and suppuration in the throat, and also suppurating 
otitis media. Pseudo-diphtheria developing, it should be 
treated with Permanganate of Potash, as recommended under 
Diphtheria. 

" As a preventive I would still recommend the potentized 
Belladonna, one dose every nigjit, until symptoms appear. If 
it cannot prevent the attack, it has seemed at least to mitigate 
its violence." (C. G. R.) 

The diet should be restricted to a non-nitrogenous one as 
far as possible, in order to relieve the kidney of any extra 
strain in its excretory work. Solid food, especially meat, 
should be prohibited until after the third week, and in case of 
nephritis developing, a milk diet must be adhered to for a 
still longer period. 

The remedies of first importance in scarlet fever are the 
following : 



ACUTE INFECTIOUS DISEASES. 653 

Aconite. — Aconite was recommended by Hahnemann in 
scarlatina miliaris. High fever ; great restlessness and anx- 
iety ; whining and moaning ; delirium, with irrational talk- 
ing ; anorexia ; mouth and throat dry ; pharynx and tQiisils 
deep-red color ; skin hot and dry. The eruption in these cases 
does not correspond to the diffuse, smooth redness character- 
istic of Belladonna, and, with full development of constitu- 
tional symptoms, the condition usually goes over into a typi- 
cal Rhus state. Personally I do not believe that the charac- 
ter of the rash is of much importance in prescribing and I 
pay more attention to the other manifestations, namely, the 
degree of fever, prostration, nervous irritability, angina, etc. 
For this reason Belladonna is a much better remedy in the 
early stages of the vast majority of cases than Aconite. 

Arsenicum. — Eruption tardy, scanty, or becoming petechial. 
Adynamic cases, with putrid sore throat ; nephritis ; dropsy ; 
typhoid state. The usual characteristics of the remedy are 
present. 

Belladonna. — " Belladonna is only indicated in the smooth 
form of eruption with vascular and nervous excitement ; it 
does no good in adynamic cases. The miliary form of erup- 
tion is much more adapted to Amm. carb., Lack, or Rhus 
tox." (C. G. R.) There is congestion of the brain, with active 
delirium ; sudden starting in sleep ; bright, glistening eyes ; 
throbbing of the carotids ; cerebral congestion ; tongue 
coated white, with red edges, the papillae showing through 
the coating ; bright redness of throat, with swelling and 
dysphagia ; pungent heat of skin, with moisture on covered 
parts. Indicated in the majority of cases in the beginning of 
the disease and if the case be a mild one, no change of remedy 
will be required. Otherwise it is usually followed by Rhus 
tox. (pronounced toxaemia); Apis (anasarca); Mercurius iod, 
rubr. (pseudo diphtheria), etc. 

Bryonia. — Delayed appearance of eruption; face crimson 
red ; mouth and lips dry ; tongue dry and brown ; great 
thirst ; the child wishes to lie perfectly quiet and undis- 



654 DISEASES OF CHILDREN. 

turbed. Bryonia is frequently indicated when rheumatism, 
synovitis or involvement of the pleura and meninges compli- 
cate the case. 

Carbolic acid is highly recommended by Goodno. 

Cuprum. — Sudden recession of the eruption, with occur- 
rence of cerebral symptoms. The Acetate of Copper is gen- 
erally preferred. The Arseniate of Copper should always be 
thought of when the condition is one of uraemia. 

Gelsemium. — In the early stages, when there is the charac- 
teristic dullness and drowsiness; aching and prostration; 
soft, compressible pulse ; aching in the eyes and back of head. 
The throat is red and feels swollen ; the eyes are suffused, and 
the patient feels chilly, especially along the spine. 

Lachesis. — Scarlatina miliaris. Eruption becoming purple 
and livid; desquamation delayed; hsematuria (Terebinthind) - 
oppression when lying down ; diphtheritic complication ; di- 
arrhoea, with foul-smelling stools. 

Rhus tox. may be indicated from the beginning when the 
rash is not of the smooth, diffuse variety, and, instead of 
vascular and nervous excitement, there is prostration, with 
great restlessness ; high temperature, with drowsiness ; tongue 
red and smooth ; epistaxis ; cedematous swelling of the skin 
in various parts, the eruption becoming dusky with the de- 
velopment of miliary vesicles ; swelling of the cervical glands 
and cellular tissue about the neck; ulceration of the throat. 

Sulphur. — Intense redness of entire body, like a boiled lob- 
ster; skin hot and dry, with great burning. 

Veratrum vir. — In the beginning, when there is great vas- 
cular excitement, wiry pulse, dilated pupils, convulsions. 
The pulse is hard and wiry, arterial tension being greater 
than in Aconite, while anxiety and restlessness are less 
marked. 

Zincum is indicated where the eruption is scanty, of a pale 
bluish-red color or entirely absent, while cerebral symptoms are 
pronounced. " Especially in the anaemic; brain exhausted; 
not able to develop exanthemata" (Hering). Meningitis in 



ACUTE INFECTIOUS DISEASES. 655 

the stage of paralysis. Convulsions followed by stupor; the 
feet are in constant motion, or the child lies perfectly motion- 
less, with eyes open, pupils dilated, cornea insensitive. When 
these symptoms are present there is little to be hoped from 
any remedy: but if we can anticipate them, and give Zincum 
on its early indications, a fatal termination may be averted. 

Remedies less frequently indicated, but of great importance 
in special cases, are: 

Ailanthus. — Miliary rash; small, rapid pulse; the eruption 
becomes dark and livid ; intense angina, with acrid discharge ; 
muttering delirium followed by stupor. 

Arum triph. — Tongue red and swollen, acrid discharge from 
nose; diphtheria, swelling of submaxillary glands; the corners 
of the mouth and the lips are cracked, and the child picks at 
the lips and finger-nails until they bleed. 

Amnion, carb., Apis, Lycop., Muriatic acid, Opium, Phos., 
Phos. ac, Phytolacca and Stramonium also bear a strong rela- 
tionship to special symptoms. 

Complications and Sequelae. — Throat complications call for 
Phytolacca, the various salts of Mercury, Kali bicJirom. y Per- 
mangaiiate of Potash, Lachesis and others. (See Diphtheria.) 

Cellulitis and Parotitis. — The most important remedy for 
this complication is Rhus tox. Suppuration calls for Hepar, 
Mercurius, Silica. 

Otitis. — Bell., Puis., Rhus tox., Pan tag o. Cerebral compli- 
cations, Apis, Bell., Helleb., Hyos., Stram., Sulph. and Zinc. 

Entero-colitis. — Mercurius usually controls the diarrhoea, 
but China, Rhus tox., Veratr. alb. may also be indicated. 

Nephritis. — Cantharis is a most valuable remedy in post- 
scarlatinal nephritis when there is not much blood in the 
urine and only moderate dropsy. When the latter is pro- 
nounced Apis and Arsenicum are of greater service. The 
characteristic "smoky" appearance of the urine frequently 
seen after scarlet fever, from the free admixture of blood, is a 
strong indication for Terebiuthina. Persistent albuminuria 
after scarlet fever calls for Mercurius corr. 



656 DISEASES OF CHILDREN. 

RUBELLA. 

Rubella, R'dtheln, or German Measles, is characterized by 
moderate fever, sore throat, and an exanthem which in some 
instances resembles that of measles (rubella morbilliforme), 
and in others that of scarlet fever (rubella scarlatintforme). 
Complications or sequelae are scarcely ever observed. It usu- 
ally occurs epidemically, and one attack gives immunity 
against another, but in nowise protects against measles or 
scarlet fever. 

Nothing definite is known of its etiology. It is contagious, 
but less so than measles or scarlet fever; nevertheless it may 
be spread by articles of clothing, etc. Infants under six 
months are immune. The incubation period averages two 
weeks, but it may show considerable variation in this respect. 

Symptomatology. — The period of invasion is short, pro- 
dromata usually being absent. Drowsiness, slight fever and 
sore throat precede the eruption by a day or more in some 
cases; in others the rash appears before the child has shown 
evidence of any illness. It is first seen upon the face, from 
which it spreads over the entire body in the course of twenty- 
four hours. Although the face is the most constant site of 
the eruption, even when the rash is developed but partially, 
still the chest and back may show the first signs of eruption 
in exceptional cases. The duration is about three days. 
Often it has completely faded from the face by the time the 
lower extremities are involved. 

In rubella morbilliforme there is seen a discrete, maculo- 
papular rash of pale red color, the eruptive points being 
slightly elevated and about the size of a pin's head or larger. 
These lesions have a tendency to become confluent upon the 
face, particularly so when they are numerous. 

In rubella scarlatintforme the rash is of a diffuse, uniform, 
scarlet color, never as intense, however, as in scarlet fever, 
and with unmistakable evidence of the maculo-papular erup- 
tive points in various localities (on the forehead, fingers and 
toes, and about the wrists). 



ACUTE INFECTIOUS DISEASES. 657 

Desquamation occurs to a slight degree after deflorescence 
of the rash, but in mild cases it may be entirely wanting. 

Catarrhal symptoms are not a necessary accompaniment of 
rubella, and throat symptoms may be so slight as to remain 
unnoticed. The slight cough present is due to an infection 
of the mucous membrane and tonsils, as in la grippe (Kop- 
LiK). In a number of my cases there was decided follicular 
pharyngitis, and in some a slight exudate was present upon 
the mucous membrane. The superficial lymphatic glands of 
the posterior cervical and posterior auricular region are tran- 
siently swollen, this being one of the characteristic symptoms 
of the disease. Usually there is also involvement of the axil- 
lary and inguinal glands. 

The duration is short, seldom over five days. The prog- 
nosis is good; complications are rather to be considered 
accidental than otherwise. 

In many instances the diagnosis can only be made after 
the mild course of the disease has been noted, in conjunction 
with the absence of complications and sequelae, especially if 
an epidemic is not known to be on at the time. When, how- 
ever, we are aware of such an epidemic, and especially if the 
child has previously had one of the other exanthemata, the 
diagnosis presents little or no difficulty. From measles it 
is chiefly to be differentiated by the absence of catarrhal 
symptoms, absence of Koplik's spots and the slight fever. 
From scarlatina the absence of the strawberry-tongue, the 
rash first appearing upon the exposed portions of the body, 
the low temperature and absence of desquamation and ne- 
phritis readily differentiate it. 

The treatment is simple in a frank case of rubella, but 
until we are aware of the true nature of the case the child 
should be cared for identically as in a case of measles or scar- 
let fever, in order to be on the safe side. Cases resembling 
measles will require remedies suited to mild cases of the same 
(Aconite, Bryonia or Pulsatilla), and those resembling scar- 
latina will usually require nothing more than a few doses of 
Belladonna. 



658 DISEASES OF CHILDREN. 

VARIOLA; VARIOLOID. 

Variola, or small-pox, is an acute infectious, highly conta- 
gious disease, characterized by fever of a typical course, vom- 
iting, intense lumbar pains, and an eruption of papules passing 
through the stages of vesicles, pustules and crust formation, 
the vesicles being umbilicated. 

The nature of the contagion has not been determined. It 
is contained in the secretions, excretions and exhalations of 
the body, being especially disseminated by means of the dried 
scales and contents of the pustule. Pfeifer and others have 
constantly found small, homogeneous bodies in the epithelial 
cells surrounding the lesions. One or two are usually found 
in the cell substance. They probably belong to the class of 
protozoa (Park). 

It attacks all ages, from the foetus in utero to the aged. A 
case came under my notice in which the eruption appeared in 
a new-born infant on the fifth day. During the last three 
weeks of her pregnancy, the mother had had an attack of vari- 
oloid, which was overlooked at the time on account of its 
mild nature. The infant died on the twelfth day. Among 
children it proves especially fatal. One attack protects 
against another, at least for a long period of time. The 
period of incubation is from nine days to two weeks. 

The pock first consists of an area of round-cell infiltration 
into the rete mucosum, in which a central area of coagulation- 
necrosis takes place. Inflammatory reaction occurs around 
this area, which represents the central depression of the ves- 
icle, with the formation of a reticulated vesicle containing 
serum, leucocytes and fibrin filaments. Pustule-formation 
supervenes, the leucocytes and cells of the rete mucosum be- 
coming necrotic. 

Symptomatology. — The invasion is marked by a severe 
chill or repeated chills, in children, often convulsions, with 
rapidly rising temperature. In children, convulsions are 
common at this period. Vomiting and intense backache 



ACUTE INFECTIOUS DISEASES. 659 

are accompanying symptoms. " In some epidemics the initial 
stage is marked by an erythematous eruption, either diffuse 
or measly, or by a hsemorrhagic exanthem which consists of 
extremely small punctate, often pin-head sized haemorrhages 
into the epidermis, at times so closely crowded together that 
the impression of a diffuse redness is produced." The tem- 
perature rises on the first day to 103 to 104 F., continuing 
with slight morning remissions until the evening of the third 
day, when it reaches its highest point. On the fourth day it 
falls several degrees, this remission lasting until the seventh 
or eighth day, when there is a secondary rise — the suppurative 
fever. 

The stage of eruption commences on the evening of the 
third day. %i There appear little red spots first in the face. If 
very numerous they coalesce, like measle-spots, with which 
they might be confounded if it were not for the granulated 
feel which they present to the sense of touch (like shot)." 
(C G. R.) 

The eruption rapidly spreads to other portions of the body, 
and on the third day of eruption the papule is converted into 
a clear vesicle presenting an umbilication at its summit. The 
vesicle is also loculated. In the course of a few T days 
(eighth day of the disease) the vesicle is transformed into a 
pustule, which dries up after a few days or breaks down, 
with the formation of a soft, yellow crust, later becom- 
ing browmish and dropping off, leaving a somewhat elevated 
spot which in time entirely disappears. This occurs where 
the lesions are discrete and where the process has not ex- 
tended into the deeper layers of the skin. Here they adhere 
for a long time, leaving an uneven scar, which at first looks 
pink, but by degrees grows conspicuously white, to remain so 
throughout life 

Simultaneously with the appearance of the eruption upon 
the skin, identical lesions develop upon the mucous mem- 
branes exposed to the external air. Here it may result in 
great destruction of tissue. 



660 DISEASES OF CHILDREN. 

Small-pox may run its course as a discrete, confluent, 
haemorrhagic, gangrenous or malignant variety. The mod- 
ified variety occurring in those partially protected by vaccina- 
tion, and running a mild course without secondary fever, is 
described as varioloid. In every other respect it is identical 
with true small-pox. 

The prognosis, excepting in varioloid, is always grave. 
As complications may be mentioned broncho-pneumonia, 
pleurisy, septicaemia, ulcerating keratitis, suppurating otitis, 
arthritis. 

The diagnosis is often rendered difficult by the primary 
erythematous eruption. The true eruption may be con- 
founded with measles in its early stages, but the sensation of 
balls of shot under the skin imparted to the finger by the 
papules of small-pox is a pathognomonic distinction, beside 
the severe initial symptoms of the attack. Again, in measles 
the temperature rises to its acme with the appearance of the 
rash, while in small-pox there is a temporary drop in the 
fever as the rash comes out. 

From varicella it is distinguished by the intensity of its symp- 
toms. Moreover, the eruption appears later than in varicella, 
does not come out in crops, is distinctly umbilicated, and pre- 
sents a well defined inflammatory areola. The eruption of 
small-pox is also decidedly harder and more palpable than 
that of varicella. 

Treatment. — As small-pox is one of the most serious and 
most dreaded of all contagious diseases, every precaution to 
prevent a spread of the same must at once be instituted when 
we are confronted by a suspicious case. The most rigid iso- 
lation and disinfection, as described under Scarlet Fei'cr, 
must be carried out to the letter. Besides this, even- 
person in the house not recently successfully vaccinated 
(within four years) should immediately undergo the opera- 
tion. The patient must have as much fresh air as possible. 
If the fever is very high sponge-baths are indicated. Osier 
(Practice of Medicine) has come to the conclusion that the 



ACUTE INFECTIOUS DISEASES. 661 

prevention of pitting is really not within the hands of the phy- 
sician. Protecting the ripening papules from light and keep- 
ing the hands atid face covered with lint soaked in cold water 
or mild antiseptic lotions is, however, to be recommended. 
The red-light treatment exerts no influence over pustulation 
(Schamberg). Later on, we should aim to prevent the crusts 
from becoming hard and dry by the free application of vase- 
line. The addition of a little Carbolic acid or Boric acid to 
the vaseline is a distinct advantage. 

In the early stages, Aconite, Bell., Bry., Gelsemium and 
RJuts tox. are to be recommended. Jahr [Therapeutische 
Leitfaderi) began all cases with I ariolinum as soon as the diag- 
nosis could be established; and if, in spite of this remedy, the 
course became a grave one, he followed with Sulphur. He 
preferred these two remedies above all others. 

Vaccininum is spoken of favorably by Goodno and others. 

From a limited personal experience with small-pox I have 
come to look upon Bryonia followed by Ah us tox. as the 
treatment mcst likely to exert a favorable influence over the 
disease. In the stage of suppuration when toxaemia sets in 
Cinchona tincture and whisky should be freely used. When 
collapse threatens it may become necessary to resort to 
Strychnia. 

VACCINIA. 

Vaccinia, or Cow-pox, is an eruptive disease of the cow, in- 
oculable into man, and producing a lesion at the site of the 
inoculation resembling the pock of variola, together with 
constitutional disturbances. No specific germ for vaccinia is 
known, nor is the true nature of the disease understood, some 
considering it a primary disease of the cow, while others be- 
lieve it to be small-pox modified by its passage through ani- 
mals. It has been experimentally demonstrated that children 
vaccinated with cow-pox were not susceptible to inoculation 
with small-pox virus, the reverse condition also holding true. 
PfeifTer and others have found small homogeneous bodies in 



662 DISEASES OF CHILDREN. 

the epithelial cells surrounding the lesions of both small-pox 
and vaccinia, and as small-pox virus has produced in cattle a 
disease indistinguishable from cow-pox, there is hardly any 
doubt that the two are due to the same micro-organism, modi- 
fied by its transmission through the cow (Park). 

A successful inoculation with vaccinia affords protection 
against small-pox in the majority of cases, at least for a num- 
ber of years. Small-pox occurring in those who have been 
vaccinated usually assumes a mild course, i. e., varioloid. As 
to the modifying influence of vaccinia upon small-pox already 
in progress there is a difference of opinion. According to 
Marson, if a person exposed to small-pox be vaccinated within 
four days, small-pox will be prevented; if later, but early 
enough to allow the vesicles to reach the stage of areola, the 
attack of small-pox will be modified ; but later than this it is 
useless. Curschmann opposes this view as erroneous. It is 
interesting to know the views expressed by Hahnemann on 
this subject, which are no doubt borne out by the most trust- 
worthy clinical testimony — "It is well known that when var- 
iola is added to cow-pox, the former, by virtue of its superior 
intensity as well as its great similitude, will at once extin- 
guish the latter homceopathically and arrest its development. 
Cow-pox, on the other hand, having nearly attained its period 
of perfection, will, by its similitude, lessen to a great degree 
the virulence and danger of a subsequent eruption of small- 
pox, for which we have the testimony of Miihry and many 
others" {Organon). 

The operation of vaccination consists of the introduction of 
the lymph from the vaccine vesicle of heifers into the circula- 
tion by bringing it in contact with a scarified surface for a 
sufficient length of time to permit of its absorption. Having 
cleansed the site of inoculation (the usual seat is the left arm, 
just below the insertion of the deltoid muscle) with soap 
and water, followed by scrubbing with alcohol or ether, a 
few parallel scratches about half an inch in length are 
made with a sterilized needle, just deep enough to break the 



ACUTE INFECTIOUS DISEASES. 663 

epidermis and expose the rete mucosum. A drop of glycerin- 
ated vaccine lymph, this being the most reliable and aseptic 
form in which the virus can be obtained, is placed upon the 
scarified surface and rubbed in gently with the needle. Guest 
(Pediatrics, Vol. IX, No. 5) has arrived at the conclusion that 
the entire contents of a tube is too large a quantity of lymph 
for the average child, judging fiom the results obtained in 
four hundred cases vaccinated by this method, in which there 
was more pronounced inflammatory reaction and more gland- 
ular swelling, besides the formation of a larger scab than in 
his former cases inoculated with points. I have, however, 
found that the old-fashioned ivory point usually causes a more 
severe lesion than the lymph, although in order to avoid an 
aggravated form of vaccination we must not scarify too freely 
or rub in too much lymph. After permitting the seat of in- 
oculation to dry, the scarification is covered with a piece of 
sterilized gauze, over which a shield or bandage is applied. 
By the adoption of this careful method, complications and 
sequelae rarely, if ever, follow. 

Symptomatology. — During the first three days after the 
operation, nothing excepting a slight local irritation, soon 
subsiding, will be noticed. On the third day, however, a 
papule appears at the site of inoculation, surrounded by an 
areola; this papule is converted into an umbilicated vesicle 
on the fifth or sixth day. The vesicle attains its maximum 
development by the eighth day, after which it becomes pus- 
tular. The areola gradually increases in size and depth of 
color until this time, but dissapears as the acute symptoms 
subside. The pustule then dries up, forming a scab. On the 
twenty-first day the scab comes off, leaving the characteristic 
deep, circular, pitted scar. 

The constitutional symptoms accompanying vaccinia are 
fever, malaise, anorexia, etc., which begin with the eruption, 
and attain their height at the period of pustulation, after 
which they rapidly disappear. Swelling of the axillary 
glands is usually present. 



664 DISEASES OF CHILDREN. 

Variations from the above-described course frequently 
occur. The vesicle may be late in developing, may be pre- 
mature and not fully developed ; a generalized pustular erup- 
tion may accompany the primary lesion, which may persist 
in recurring attacks after healing of the same ; or complica- 
tions, notably erysipelas, ulceration and sloughing, glandular 
abscesses and septicaemia, may develop as the result of faulty 
technique. Vaccinia may also occur as a general eruption of 
papules, which turn into vesicles and pustules. They appear 
on the face and extremities about the fifth day. I have 
also encountered a general papular rash occurring on the 
tenth day, looking like measles or the early stage of small-pox. 

Deaths have occurred, but they were almost invariably from 
avoidable causes, as Voigt shows in his statistics. There is 
always a risk, however, in vaccinating a delicate, sickly child, 
and the operation should never be performed when an acute 
disturbance is present, or if there is a case of contagious dis- 
ease in the family to which the child has been exposed. I 
have observed some anti-vaccinationists vaccinate, and their 
careless method has convinced me that they had good cause 
to be dissatisfied with this practice. 

Besides, the in vaccination of syphilis (when humanized 
virus was used) has occurred, and claims have been made 
that tuberculosis was likewise transmitted. This, however, 
has not been proved, although vaccination may have been, in 
some instances, the exciting cause in stirring up a latent 
tuberculous lesion in strumous and tuberculous children into 
an acute condition. 

The age at which children are vaccinated is usually the 
third month, in the absence of any acute or constitutional ill- 
ness. In the absence of an epidemic of small-pox I do not 
see the necessity for so prompt a procedure. It is quite early 
enough to vaccinate the child after it is out of its teething 
difficulties, and some physicians, believing in the efficacy of 
vaccination to control whooping-cough, keep it in reserve to 
be employed as the opportunity manifests itself. The child 



ACUTE INFECTIOUS DISEASES, 665 

should, however, be vaccinated before it is sent to kindergar- 
ten or school, and revaccinated at the period of puberty, or on 
the occurrence of an epidemic of small-pox. 

Treatment. — After vaccination I give Aconite, following 
the same with Belladonna if fever, headache, diffuse redness 
and swelling about the site of eruption and glandular swell- 
ing develop. Apis or Rhus may be indicated by erysipelatous 
manifestations. After the acute symptoms have subsided it 
is well to give a few closes of Sulphur, or if the scab separates 
with suppuration and an unhealed ulcer remains, Silica. I 
firmly believe that when vaccination is carried out on strictly 
aseptic lines, and the child is watched throughout as in the 
case of any other illness — being put to bed if necessary, and 
carefully prescribed for — none of the many complications and 
so-called constitutional after-effects, attributed to vaccination, 
will follow. The complications and sequelae of improper vac- 
cination and the constitutional disturbances caused by the 
same will require symptomatic treatment. The remedies 
most frequently recommended are Thuja. Silica, Malandri- 
num and Sulphur. 

VARICELLA. 

Varicella, or chicken-pox, is an acute infectious disease char- 
acterized by the eruption of discrete vesicles, which appear in 
crops, and disappear, in the course of a few days, by desicca- 
tion. 

The specific virus has not been isolated, but it is known to 
exist in the vesicles, and can be transmitted by inoculation. 
The usual manner of contracting the disease is through con- 
tact with a case, although a third person may carry the infec- 
tion. One attack protects against another. It may occur 
sporadically or epidemically. The period of incubation is 
usually two weeks. 

The symptoms are slight in the majority of cases, but they 
may assume such a grave nature in delicate children, espe- 
cially in the tuberculous, that the diagnosis may present some 

43 



666 DISEASES OF CHILDREN. 

difficulty. However, the subsequent course of the disease 
will remove all confusion in the matter. The onset is abrupt, 
as a rule, the first signs of the disease being the appearance of 
papules and vesicles upon the trunk and extremities, accom- 
panied by slight fever, anorexia, coated tongue and languor. 
Constitutional symptoms may be so slight as to attract no at- 
tention. Each day a new crop of vesicles makes its appear- 
ance ; this usually continues for three or four days. 

The eruption appears first as a small red papule, soon be- 
coming vesicular. The vesicles are unilocular, although at 
times multilocular vesicles are seen. They are surrounded 
by a faint areola, and do not become pustular unless infected 
by scratching, etc. In the course of a few days they dry up, 
the crusts soon falling off without leaving a scar, although in 
some cases a circular, pale area is left, which persists for some 
time, or, if ulceration has taken place, quite a conspicuous 
scar may remain. 

Varicella gangrenosa is a type of varicella which is at- 
tended by gangrenous stomatitis, as a result of infection in 
poorly-nourished or tuberculous children. If the process be- 
comes extensive, it may prove fatal. As complications — 
which, however, are fortunately rare — may be mentioned 
erysipelas, adenitis, cellulitis, gangrenous dermatitis and ne- 
phritis. It is not uncommon to have varicella and one of the 
other infectious fevers occur simultaneously, although the 
error must not be made of considering those cases of varicella 
beginning with an erythematous or measle-like rash as cases 
of varicella plus scarlet fever or measles. 

Diagnosis. — Varicella is to be differentiated from small-pox 
by the slight constitutional disturbances accompanying the 
rash, which appears abruptly, coming out in crops, and soon 
disappearing by dessication, without pustulation or scar-for- 
mation. The eruption of small-pox does not always come 
out at once, and frequently new papules and vesicles will con- 
tinue to appear for several days after the first lesions were 
seen. They do not, however, erupt in distinct crops, nor do 



ACUTE INFECTIOUS DISEASES. 667 

we find lesions in the various stages of development, that is, 
fresh papules and vesicles interspersed among pustules, as is 
to be observed in varicella. Again, the papules of varicella 
lack the shot-like feel characteristic of the small-pox lesion, 
and the vesicles are more delicate and present a characteristic 
pearl-like appearance. If the vesicle has not dried up by the 
fourth da}', it is more likely small-pox than varicella. 

Treatment. — In the presence of fever, rest in bed, a light 
diet, and, when there is much itching, the use of rye-flour as 
a dusting-powder, or olive oil and Boric acid, is about all that 
is required in mild cases. Aconite may be called for in the 
beginning, to be followed by Rhus tox. The gangrenous or 
pustular variety will call for Arsenicum, Merairius, Rhus 
tox., etc. 

PERTUSSIS. 

Pertussis, or whooping-cough, is an acute infectious disease 
in which there is present a catarrhal process of the respirator}- 
tract and a characteristic paroxysmal cough. It occurs both 
epidemically and sporadically, infection taking place through 
close proximity to a case ; seldom through the agency of a third 
person. Close proximity, however, is necessary, as the air 
does not seem to convey the contagion to any great distance, 
about the patient. Epidemics are said to occur every 
eighteen months or two years in large cities, as in measles. 

Several micro-organisms have been credited with being the 
exciting cause. Afanassjeff isolated a short bacillus, the 
bacillus tussis convulsive?, but failed to demonstrate satisfac- 
torily the reproduction of whooping-cough by inoculations 
with pure cultures of this bacillus. The investigations of 
Czaplewski point to another bacterium as the contagium 
vivum ; this bacterium is two or three times as long as broad, 
rounded and somewhat thickened at its ends, is divided in 
the middle, and surrounded by a capsule in its natural state-. 
The secretions of the normal mucous membrane of the nose 
contain very few bacteria, while in whooping-cough we find 



668 DISEASES OF CHILDREN. 

a large mass of this particular kind, in fact, a natural pure 
culture (Wagner, N. Y. Med. Jour., Oct. 8, 1898). The 
most recent studies of the secretion expelled after a coughing 
paroxysm have shown a short, ovoid bacillus, similar in ap- 
pearance to, and of the same group as, the influenza bacillus. 
The bacillus grows best upon blood-agar and agglutinates 
with the blood of pertussis patients in as high as 1-200 dilu- 
tion (Martha Wollstein). 

The contagion exists mainly in the sputum, and the pa- 
tient should be considered capable of spreading infection as 
long as the cough retains its characteristic paroxysmal na- 
ture. The period of incubation is from one to two weeks. 

The pathological processes accompanying whooping-cough 
are catarrhal inflammation of the larynx, particularly in the 
region of the inter arytenoid cartilages; tracheitis and more 
or less bronchitis ; swelling of the bronchial glands ; rhinitis. 
In fatal cases broncho-pneumonia with emphysema and areas 
of atelectasis are the most common lesions found ; there may 
also be entero- colitis and cerebral congestion, with effusion 
and cortical haemorrhages. The toxin of whooping-cough in 
'some cases appears to affect the smaller blood-vessels and 
favor haemorrhagic extravasations, either spontaneous or as a 
Result of the congestion which is associated with the cough- 
paroxysm. Moebius believes that the nervous system may 
also be acted upon by this toxin in a manner somewhat 
similar to the action of the diphtheria toxin. 

Symptomatology. — The course of whooping-cough is in 
three stages : the premonitory, or catarrhal ; the spasmodic, 
and the stage of decline. The first stage usually lasts ten 
days to two weeks ; the second stage may persist for a month 
or more ; while the stage of decline is a gradual transition 
into an ordinary bronchial cough, which varies with the state 
of the child's health and with the season of the year. The 
average duration of an ordinary case is, therefore, about six 
weeks, but the course is greatly influenced by treatment and 
also by the advent of complications. 



ACUTE INFECTIOUS DISEASES. 669 

The attack begins as an ordinary cold, indistinguishable in 
the beginning from a simple bronchitis, with, however, this 
difference, that instead of yielding to treatment in the course 
of a few days, or abating of its own accord, the cough 
gradually increases in frequency and severity, soon assuming 
the paroxysmal and spasmodic type characteristic of the dis- 
ease. An early symptom that should always arouse suspicion 
is the nocturnal aggravation of the cough from the very be- 
ginning. 

Examination of the chest at this time reveals nothing be- 
yond a slight bronchitis. In the very beginning there is 
usually indisposition, running of the nose, a short, dry 
cough, and slight fever. These symptoms soon abate, but 
the cough increases in severity. The cough is characterized 
by a sudden, loud expulsive effort, followed in rapid succes- 
sion by similar efforts of gradually decreasing force ; through 
these continued explosions the chest is almost completely 
emptied of air, so that the child is obliged to draw in a deep 
breath at the end of the paroxysm. As the glottis is nar- 
rowed during this long-drawn inspiration, a loud, piping 
sound is produced, constituting the whoop, from which the 
disease is named. As soon as the lungs have been refilled 
the cough begins anew, consisting, as before, of rapidly fol- 
lowing expulsive efforts, ending with the whoop. This con- 
tinues (two to six coughing fits) until the paroxysm is ter- 
minated either by the dislodgement of a plug of mucus from 
the trachea, or by the vomiting of the ingesta or of a quan- 
tity of tenacious mucus. 

During such an attack the face becomes red, even livid ; 
the eyes are injected and bulging, and the child clings to the 
nearest object for support, or stands with the feet wide apart 
and the hands resting upon the knees. Bleeding from the 
nose frequently occurs during the paroxysm, and cortical 
haemorrhages from the meningeal vessels are to be feared in 
violent cases. When such a haemorrhage is extensive, hemi- 
plegia and convulsions will follow. This haemorrhagic ten- 



670 DISEASES OF CHILDREN. 

dency is one of the most serious aspects of whooping-cough. 
Sub-con junctival haemorrhage is quite common. No doubt 
the action of the pertussis toxin upon the blood-vessels is re- 
sponsible for the condition. 

The number of paroxysms in a day will vary from only a 
few to as many as fifty. They are usually more frequent 
during the night. In very young children the cough is not 
as characteristic as in older ones, the whoop being especially 
faint or indistinct, but the same paroxysmal nature of the 
cough is present, and, indeed, they may suffocate during a 
severe spell. 

There are signs upon which we can base a fairly positive 
opinion as to the existence of whooping-cough in most cases, 
even without having heard the cough. But it is rarely neces- 
sary to exclude this pathognomonic symptom, for should the 
child evince no desire to cough during our examination it is 
but necessary to press the finger into the jugular fossa, or 
irritate the pharynx with a tongue depressor, in order to 
bring on a paroxysm. The face appears bloated from the re- 
curring vascular enlargement, and the eyes are deeply in- 
jected ; slight haemorrhages may be seen under the conjunc- 
tiva. The eyes are unnaturally moist. Under the tongue a 
characteristic sign is frequently seen, namely, ulceration of 
the fraenum. This is induced by the repeated propulsion of 
the tongue over the lower incisor teeth in coughing. In my 
experience it has only been present when there was at the 
same time catarrhal stomatitis in association with the whoop- 
ing-cough, rendering the mucous membrane particularly vul- 
nerable. 

With the decline of the disease the paroxysms become less 
frequent and less severe, soon losing the spasmodic char- 
acter of the cough, and the expectoration becomes muco- 
purulent, as in an ordinary bronchitis. With a fresh cold 
the whoop may reappear ; this, however, is to be considered 
rather as an intensification of the cough in a subject in whom 
the spasmodic habit has been formed than as a true recur- 
rence of the disease. 



ACUTE INFECTIOUS DISEASES. 671 

The commonest complications of whooping-cough are 
broncho-pneumonia (in the winter months) and entero-colitis 
(summer months). The advent of broncho-pnenmonia is 
recognized by the appearance of fever, together with rapid 
respirations and dyspnoea, and subcrepitant rales throughout 
the chest. The cough may change during the height of such 
a complication, assuming more the incessant, dry or rattling- 
character belonging to broncho-pneumonia. In a case seen 
in consultation a five year old child was suddenly seized dur- 
ing the fourth week of whooping-cough, with a high fever 
and cerebral symptoms so pronounced as to suggest menin- 
gitis. Examination of the chest revealed croupous pneumonia 
of the right upper lobe. 

Diarrhea is liable to become a troublesome symptom in 
delicate children, often leading to marasmus. 

Convulsions due to extreme general nervous irritability are 
frequent among infants. They may, however, be due to 
asphyxia, meningeal haemorrhage (see p. 511), or pneumonia, 
giving the case an entirely different aspect. Meningitis 
rarely, if ever, results from whooping-cough, although marked 
meningeal symptoms due to hyperaemia of the brain and 
oedema of the pia mater may be observed. 

Dilatation of the heart, due both to the strain on the heart 
as well as to the action of the toxin upon the myocardium, 
may be observed (Koplik). 

As a sequela, tuberculosis is most to be dreaded. Whoop- 
ing-cough, as is well known, is one of the most potent pre- 
disposing causes of tubercle, ranking second to measles in 
this respect. This is due to the fact that in both of these 
diseases inflammation of the bronchial glands occurs promi- 
nently. 

The prognosis depends to a great extent upon the age and 
previous health of the child. Normal children above five 
years of age seldom suffer great inconvenience or serious after- 
complaints under proper treatment. The prognosis becomes 
grave when broncho-pneumonia is added, or where the hsem- 



672 DISEASES OF CHILDREN. 

orrhagic tendency is marked ; and in infants (notably the 
rachitic and tuberculous) the prognosis should be guarded. 

Diagnosis. —During the prevalence of an epidemic the diag- 
nosis should present no difficulties. Isolated cases, however, 
may become puzzling, especially when atypical. The char- 
acter of the cough, together with the accompanying signs 
described under the symptomatology, should bear one out in 
differentiating whooping-cough from an ordinary bronchitis. 
The pertinacity and intensity of the cough, with the absence 
of all other signs indicating a thoracic condition commensur- 
ate with such a cough, is characteristic. 

Prof. Filatow, of Moscow, confirms the researches of Hip- 
pius and Blumenthal, who noticed that pertussis patients 
have a pale urine of high specific gravity. 

Hyperplasia of the bronchial glands frequently provokes a 
paroxysmal cough, but the course is a chronic one, and there 
is associated bronchitis, and usually tuberculous foci else- 
where in the chest. Other possibilities of error are found in 
the so-called "spasmodic broitchitis" of infants, and catarrhal 
laryngitis (false croup). 

Treatment. — Isolation is difficult to carry out, as the dis- 
ease is already contagious during the stage at which it cannot 
always be recognized. Nevertheless, every effort should be 
made to protect delicate children and infants against exposure 
by excluding from their presence, during an epidemic, all 
children with suspicious colds or hacking coughs. 

The patient should receive as much air as possible, and in 
pleasant weather may be permitted to be out-of-doors. Pro- 
tracted cases do well from a change of climate, the seashore 
being particularly beneficial. 

If the cough is very troublesome at night, and especially in 
the case of infants in whom asphyxia is to be feared, the vap- 
orizing of Cresoline, Creasote or Oil of Eucalyptus va the sick- 
room is often attended with the happiest results. Holt pre- 
fers Creasote, vaporized in a croup-kettle; a weak Formalde- 
hyde vapor is also of service at times in mitigating the parox- 
ysms. 



ACUTE INFECTIOUS DISEASES. 673 

The remedies recommended for whooping-cough are legion, 
and space forbids enumeration of so long a list. While there 
are, perhaps, a dozen which are used a hundred times when 
the others are used but once, still it is impossible to tell just 
which remedy will be of the greatest benefit in a given case 
before the symptoms have been carefully considered. The 
popular feeling as to the clinical value of our remedies in this 
affection is well presented by the following statistical report 
by Dr. Geo. B. Peck (Trans. American Institute of Homoeop- 
athy, 1898): "Out of every thousand prescriptions by mem- 
bers of this Society for the amelioration of that group of mor- 
bid phenomena popularly designated whooping-cough, at least 
175 are for Drosera, 153 for Belladonna, 123 for Ipecacuanha, 
76 for Cuprum (metallicum and aceticuni), 54 for Coralliuni 
rubrum, 44 for Antimon. et pot. tartaricum, 24 for Mephitis, 
20 each for Aconitum napellus and for Hyoscyamus, 18 for 
Naphthalin, 15 for Coccus cacti, 13 for Kali bicJiromicum, n 
for Bryonia, 9 for Magnesia phosphorica, 8 for Chelidonium 
majus," etc. 

In the early stages Aconite, Bell., Ipecac, or Tartar emet. 
may be indicated. As soon as the true nature of the case be- 
comes apparent a remedy should be given capable of control- 
ling the course of the disease. Opinions differ as to the most 
potent remedy to accomplish this result. No doubt the rem- 
edy will vary with the epidemic, and while Drosera, Bella- 
donna, Naphthalin, etc., are useful in many instances, they 
are not invariably so. As soon as the cough is accompanied 
by the raising of secretion I am in the habit of prescribing 
Tartar emetic, 2x trit., unless indications point strongly to 
another remedy, such as Ipecac. 

If, in spite of the administration of one of the above-men- 
tioned remedies, the case continues steadily to advance or be- 
come of a more serious type, ( 'ufirum, Mephitis, C or allium 
rubruni, Coccus cacti and Hyoscyamus should be thought of. 
Protracted cases will often yield to ( arbo veg. with remark- 
able promptness. 



674 DISEASES OF CHILDREN. 

Ambra ginsea. — Hollow, paroxysmal cough, with expecto- 
ration of tough, grayish or yellowish mucus, especially after 
awaking in the morning ; belching after cough. 

Anacard. — Ill-natured children, with uncontrollable tem- 
per ; cough brought on by fits of vexation {Ant. crud. — 
Great irritability ; disagreeable toward these of whom it was 
formerly very fond, even striking at them.) 

Arnica. — Painful paroxysms (Bryonia); tendency to haemor- 
rhages ; meningeal haemorrhage. 

Bell. — Intense redness of face during paroxysm ; nervous 
erethism ; convulsions ; eyes bloodshot ; cough deep and 
hollow ; sneezing after cough. The most important remedy 
in the early stage. 

Car bo veg. — Protracted cases. Follows well after Drosera. 
Hoarseness ; anaemia ; sluggish circulation ; flatulent indi- 
gestion. 

Coccus cacti. — Cough, especially worse in the early morn- 
ing, followed by the expectoration of yellowish or bloody, 
tough mucus (Ambra grisea). I have had excellent results 
with this remedy during the paroxysmal stage, when there 
was abundant stringy, yellowish expectoration. 

Cuprum,. — Convulsions ; the paroxysms are severe and long- 
continued, the child becoming blue in the face ; cerebral com- 
plications (follows well after Ipecac). 

Drosera. — Paroxysmal stage. Worse after midnight ; gag- 
ging and vomiting predominate ; the expectoration is fre- 
quently blood-streaked ; tuberculous diathesis. Personally, 
I have been disappointed in the results seen from this remedy. 

Hyos. — Incessant cough when lying down, relieved by 
sitting up. 

Ipecac. — Spasm of the glottis before paroxysm ; the child 
stiffens out during the cough and becomes blue in the face (a 
strong indication for Ipecac in my experience). Broncho- 
pneumonia, with abundant fine rales ; vomiting after cough. 
The expectoration is often blood-streaked. Hughes recom- 
mends beginning all cases with Aconite and Ipecac in 
alternation. 






ACUTE INFECTIOUS DISEASES. 675 

Mephitis. — During the spell the child passes both urine 
and faeces ; diarrhoea and flatus very offensive ; the child 
must be taken up during the cough, turns blue in the face 
and seems asphyxiated. In a number of grave cases in in- 
fants, in whom suffocation seemed imminent, Mephitis in the 
second decimal dilution has given me excellent results. 

Naphthalin. — Goodno recommends this remedy to be used 
as soon as the case is recognized. He employs the first deci- 
mal trituration. 

Tartar emetic. — Broncho-pneumonia. Rattling of mucus 
in larger tubes ; gasping for air ; deficient oxygenation of 
blood. I have in late years obtained the best results from 
this remedy as a routine prescription when another remedy 
was not strongly indicated. 

Sulphur may be required in the third stage, if the patient 
relapses into his former condition on the slightest provoca- 
tion {Car bo veg.). 

PJienacetine and Antipyrine are much used by the old 
school. Hale recommends Phenacetine in the ix trituration, 
two to ten grains ever}- three to four hours. 

PAROTITIS. 

Epidemic parotitis, or mumps, is an acute infectious disease 
in which the parotid glands are attacked by an intense catar- 
rhal inflammation. The specific contagion is not known, but 
it no doubt gains access into the gland through the duct of 
Steno, setting up an intense hyperemia, followed by a profuse 
serous exudation (soft swelling). The process begins in the 
ducts and acini of the gland, rarely extending to the inter- 
stitial connective tissue, and only terminating in suppuration 
when there is an accidental infection with pyogenic micro- 
organisms accompanying the primary infection. For this 
reason resolution is perfect in the vast majority of cases, as the 
tumefaction is the result simply of hyperaemia and oedema 
and not of structural changes in the gland. 



676 DISEASES OF CHILDREN. 

Secondary parotitis is an infection of the parotid gland 
(usually one-sided), with pyogenic micro-organisms, occurring 
during the course of one of the infectious fevers. It may com- 
plicate typhoid fever, diphtheria, scarlet fever, small-pox and 
measles, rendering the prognosis most grave. In these 
cases the submaxillary gland is rarely spared. Unlike as in 
mumps, it terminates in suppuration, the entire parenchyma 
of the gland being more or less involved in the destructive 
process. 

Mumps appears epidemically, although never to the extent 
attained by epidemics of the other prominent contagious dis- 
eases of childhood. Close contact seems necessary for infec- 
tion. It is most prevalent during the damp seasons and 
among those living in damp dwellings. The period of incu- 
bation is from two to three weeks. One attack gives immu- 
nity against another. 

Symptomatology. — For a day or two there may be a slight 
fever with lassitude, restless sleep, nervous irritability, loss of 
appetite, etc., preceding the appearance of the characteristic 
lesion. The inflammation of the gland induces first a pain- 
ful stiffness of the jaw and tenderness in the region of the 
parotid. Swelling rapidly sets in, and in the course of a few 
days the gland will be swollen to its utmost extent. The 
fever may increase and the sleep become disturbed by restless 
dreams or delirium ; convulsions have been known to occur 
in young children. The left parotid is the one most fre- 
quently attacked first. In the majority of cases the opposite 
side begins to swell in a day or two after the appearance of 
the first lesion. Sometimes the opposite parotid is not in- 
volved until the first begins to subside, or it may escape en- 
tirely. 

At the height of the disease the face presents a ludicrous 
appearance. The entire parotid region stands out promi- 
nently from the presence of a tense, shining swelling which 
spreads anteriorly to the zygoma and posteriorly to the sterno- 
cleido-mastoid. The tumor feels firm over its centre while 



ACUTE INFECTIOUS DISEASES. 677 

the edges pit on pressure. The enlargement is uniform and 
regular, not nodular as in lymphadenitis. It is also perfectly 
immovable, for the parotid gland is so firmly held clown by 
the deep fascia as to render its displacement impossible. 

The fever now gradually subsides, usually not lasting more 
than from three to four days, but the patient is extremely 
uncomfortable, every effort at opening the mouth being at- 
tended with pain, and any article of food not bland in char- 
acter frequently exciting intense suffering. In fact, the ex- 
cruciating pain produced by taking anything acid into the 
mouth is looked upon as pathognomonic and a symptom of 
diagnostic value. The swelling attains its height within 
three or four days, subsiding by the end of a week. This, as 
has been above stated, is accomplished rapidly and perfectly, 
and persisting permanent structural changes should lead to a 
suspicion of a mixed infection istapJiylococci or tubercle 
bacilli). 

Metastases to the testicle in the male and to the ovary or 
breast in the female are not uncommon in older children at 
this time, /. £., during the stage of decline, but in young chil- 
dren this does not occur. Aside from the possibility of such 
a complication the pi-ognosis is good. 

Secondary parotitis occurs during the course of one of the 
acute infectious diseases, and begins as a hard, painful swell- 
ing, more circumscribed than in mumps, with an inflamma- 
tory blush soon showing itself over the surface. This grad- 
ually deepens in color; the swelling becomes more tense, and 
points of fluctuation can be elicited. In the cases which I 
have seen the sub-maxillary gland was also involved. One case, 
complicating typhoid fever, proved fatal. If allowed to open 
spontaneously there is a free discharge of thin, sanious pus. 
The prognosis is always grave, although it is said to be less 
so w T hen occurring later in the course of the disease which it 
complicates. 

Diagnosis. — It seems unnecessary to call attention to the 
question of diagnosis in a simple case of mumps, yet errors 



678 DISEASES OF CHILDREN. 

are sometimes made. One of the most frequent is the mis- 
taking of acutely enlarged cervical lymphatic glands for 
mumps ; here the slower onset, the multilocular feel of the 
tumefaction and its movability will readily distinguish this 
condition from mumps. Diphtheria, with pronounced swell- 
ing of the cellular tissue of the neck, has likewise been mis- 
taken for mumps, as I have personally witnessed. The possi- 
bility of such an error occurring can only impress us most 
forcibly with the importance of a routine inspection of the 
throat in every acute febrile disease of childhood. 

Treatment. — The most important remedy is, no doubt, 
Belladonna. It corresponds to the vascular engorgement, the 
fever, and the nervous irritability so common in mumps. 

Mercurius may be indicated early when there is but slight 
fever, pale swelling of the parotid region and gastric derange- 
ment. It is useful in the later stages of all cases to hasten 
resorption of the exudate. 

For metastasis to the testicles Pulsatilla and Clematis are 
the chief remedies. If induration with tendency to atrophy 
follows, Aurum should be considered. 

Metastasis to the ovaries calls for Apis, Colocynthis, Pulsa- 
tilla, Hamamelis. 

Secondary parotitis finds in Rhus tox. its most appropriate 
remedy. As the process advances, Hepar or Arsenic 
usually becomes indicated. Calc. sulph. is the main remedy 
to promote healing after pus has been discharged either 
through fistulous openings or by means of an incision. As 
soon as the gland becomes swollen, hot fomentations wrung 
out of a i to 4,000 solution of the Bichloride of Mercury 
should be applied continuously. This offers a hope of abort- 
ing, or, at least, limiting the process. 

INFLUENZA. 

Influenza, or la grippe, is an infectious disease occurring 
pandemically and attacking all ages alike. It is character- 
ized by fever of sudden onset and short duration, accompanied 



ACUTE INFECTIOUS DISEASES. 679 

by marked prostration and complicated with either catarrhal 
inflammation of the respiratory or alimentary tract, or by cer- 
tain nervous phenomena. This is the true influenza, and it is 
to be distinguished from those endemic cases of so-called 
grippe, catarrhal fever or epidemic bronchitis which occur 
in children with great regularity every year, especially during 
the fall and winter months. 

The bacillus of Pfeiffer is the exciting cause, being found 
in almost pure culture in the sputum of freshly infected cases. 
It is a short, thin rod with rounded ends; it does not stain 
by Gram's method and is best demonstrated with dilute 
fuchsin. It is difficult to cultivate ; besides, it usually disap- 
pears from the sputum early and for this reason its presence is 
often missed. 

The period of incubation is short, seldom exceeding a few 
days. One attack does not afford immunity against another, 
as is the case in many of the epidemic infectious diseases ; on 
the contrary, it may even lead to an increased susceptibility 
to a fresh attack, or, at least, to acute catarrhal affections. 

While influenza, as a rule, pursues a short and acute course, 
nevertheless it shows a tendency to become protracted in 
many instances, sometimes becoming latent for a while and 
then suddenly flaring up with acute manifestations. Again, 
bronchitis may persist for weeks, the secretion showing in- 
fluenza bacilli in pure culture (OrTNER, Modern Clinical 
Medicine, 1905) and pneumonia of a protracted course may 
likewise be due to the influenza bacillus, these cases present- 
ing particular difficulty in their differentiation from pulmon- 
ary tuberculosis (Wassermann). Again, certain cases of 
protracted catarrh of the respiratory tract running their course 
under the type of remitting and intermitting fever were first 
recognized by Filatow as a chronic form of influenzal infec- 
tion {Vorlesungen it. Infections-Krankk* in/ A'iudesal/cr, 1897). 

Symptomatology. — The disease begins abruptly with fever, 
severe headache, general aching and prostration. The fever 
remains at its height for a period of from three to five days, 



680 DISEASES OF CHILDREN. 

in the absence of complications, during trie entire course 
of which prostration is marked, and headache and muscular 
aching are usually very distressing. A symptom present at this 
time and upon which Fiirbringer, of Berlin, lays great stress, 
is marked redness of the face. This shows itself as a diffuse 
flush and differs from scarlet fever in the absence of the white 
line about the mouth and pallor of the forehead. As Fiir- 
bringer also points out, there is often present a slight icteric 
discoloration of the skin, although there is not much evi- 
dence of bile in the urine. I have in a few instances observed 
actual jaundice develop during influenza. Several clinical 
types are to be encountered, depending upon the predomi- 
nance of catarrhal or nervous symptoms and the locality 
chiefly attacked. 

Thus, there is the cerebral form, characterized by a pre- 
dominance of headache, together with delirium, and even un- 
consciousness, some of these cases simulating meningitis ; the 
abdominal form, characterized by vomiting, anorexia, gastral- 
gia, diarrhoea, some with predominance of gastric symptoms, 
others simulating typhoid fever ; the neuralgic form, in which 
there are neuralgic pains in the peripheral nerves and other 
regions ; the thoracic form, complicated by broncho-pneu- 
monia, and the catarrhal form, the commonest variety, in 
which catarrh of the upper respiratory tract is the most 
prominent symptom. Extreme prostration, however, is com- 
mon to all forms, this being the chief feature of the disease. 
The toxin exerts a most potent influence upon the nervous 
system, which manifests itself as prostration, cardiac weakness 
and neuralgic pains, and during convalescence in the persisting 
prostration and the strong tendency to the development of 
neurasthenia, perineuritis, insomnia, persistent headache, and 
even insanity. Fortunately these complications are not as 
common in children as in adults, and, taken altogether, 'the 
prognosis is better, although a complicating broncho-pneu- 
monia may change the entire aspect of the case. As in the 
case of measles and whooping-cough, a predisposition to in- 
fection with the tubercle bacillus is created. 



ACUTE INFECTIOUS DISEASES. 681 

Nephritis may occur in influenza ; sometimes this is of the 
haemorrhagic type. 

Rhinitis and otitis (see p. 532) are frequent troublesome 
complications. 

The pneumonia complicating influenza is a most serious af- 
fection, as a rule leading to diffuse and catarrhal inflammation 
of the finest tubes with pronounced dyspnoea and toxaemia, 
while consolidation is inconsiderable. Lobar pneumonia, 
however, appears to occur with striking frequency during 
grippe epidemics and the two diseases may occur simul- 
taneously (see p. 284, 290). Pleurisy, with " clay-water 
effusion " (Furbringer), and abscess of the lung may com- 
plicate such a pneumonia. 

The prognosis depends upon the age of the patient, the 
previous health and the presence of complications. Filatow 
lavs stress upon the fact that in childhood it is mainly during 
the first to third year that the grave cases are encountered. 

The diagnosis seldom presents difficulties during the preva- 
lence of an epidemic, but isolated cases may be mistaken for 
a variety of other affections, particularly in the beginning. 
The catarrhal symptoms, hard cough and drowsiness may lead 
to a suspicion of beginning measles, but the subsequent course 
soon corrects this error. From pneumonia it is to be distin- 
guished by the absence of physical signs indicating lung in- 
volvement, absence of extreme prostration and comparatively 
short course. The majority of cases simulate pneumonia more 
closely than any other disease, and a careful, daily physical 
examination of the chest is necessary in order to differentiate 
the two affections. Bacteriological examination of the spu- 
tum and nasal secretion may or may not throw a positive 
light upon the subject. Cerebral cases may simulate menin- 
gitis or cerebrospinal meningitis. The mild cases of grippe 
above alluded to present none of the profound toxic manifes- 
tations of influenza, being nothing more than an infectious 
rhinitis or bronchitis. In protracted cases the condition is 
often very puzzling. Such cases especially simulate tubercu- 
44 



682 DISEASES OF CHILDREN. 

losis. Here the absence of physical signs of tuberculosis and 
the bacteriological examination of the mucous secretions are 
the most conclusive diagnostic data. 

In cases of influenza in which pulmonary consolidation oc- 
curs as a complication the differentiation from primary 
croupous pneumonia rests upon the following data, according 
to Filatow (loco cit.): (a) Mode of onset, whether with catar- 
rhal symptoms or with a chill, (b) The presence of an epi- 
demic or occurrence of other cases of influenza in the same 
house, (c) The time of occurrence of the physical signs of 
consolidation, i. <?., whether demonstrable in the first three to 
five days or not until a later period, {d) The age; in children 
under three years croupous pneumonia more frequently com- 
plicates influenza than in older children, in whom it is more 
likely to be primary, (e) The clinical course ; influenzal-pneu- 
monia runs a protracted, irregular course ; the fever is remit- 
ting and relapses are common. 

Treatment. — The child should be put to bed immediately, 
absolute rest enforced, and great care taken to avoid exposure 
to cold or draughts, in order to ward off serious pulmonary 
complications. 

The diet should be highly nutritious, but to prevent gastro- 
intestinal complications, easily digested food only should be 
selected. When the pulse becomes weak and irregular a 
moderate amount of whisky should be administered at regular 
intervals. 

During convalescence much can be done to ward off the 
many sequelae belonging to influenza by rebuilding the child's 
constitution as quickly as possible with appropriate diet, rem- 
edies and hygienic measures. During convalescence, and in 
protracted cases, there is nothing more desirable than a change 
of climate, the seashore being particularly beneficial to these 
patients. 

The most important remedies for the average case are 
Aconite, Gelsemium and Bryonia in the beginning (Gelsem- 
tum and Bry. frequently suffice for the entire course of the 



ACUTE INFECTIOUS DISEASES. 683 

disease), and later we must choose from such an array as Ar- 
senicum, Euphrasia, Allium cepa, Phosphorus, Kali bichrom., 
Rhus tox., Antimon. tart., Pulsatilla, etc., according to the 
preponderance of disturbances of a certain type or in certain 
localities. 

Arsenicum is indicated where the prostration is extreme 
and presents the chief manifestation of the disease. This is 
often seen in infants. There may also be sneezing ; acrid, 
watery coryza ; the process extending to the chest, with cough 
and dyspnoea; great restlessness. 

Belladonna. — Cerebral cases; starting in sleep, delirium, 
throbbing headache. 

Bryonia. — Pains in the muscles, every limb aching in- 
tensely ; lies perfectly quiet and does not wish to be disturbed ; 
dry, painful cough. Broncho-pneumonia complicating influ- 
enza [Ant. tart., Phosphorus). 

Eupatorium perf. — Deep-seated aching in the back and ex- 
tremities, as if the bones would break ; the skin is slightly 
jaundiced and the tongue heavily coated ; bilious vomiting. 

Gelsemium. — The symptomatology of Gelscmium presents 
a true picture of the average case of grippe. The condition 
begins with lassitude and chilliness ; "creeps" especially up and 
down the back, and the patient hugs the stove to get warm. 
He feels prostrated, every part of the body aches, and he com- 
plains of headache, soreness and sensitiveness of the eyes, ob- 
struction of the nose, sore throat and prostration. The full, 
low tension, rapid pulse, heavy eyelids and flushed appearance 
of the face are very characteristic of Gelscmium. Baptisia 
should be administered if this condition does not promptly 
improve under Gelsemium. 

Pulsatilla. — Catarrhal symptoms predominate; mild, tear- 
ful disposition; the tongue is heavily coated and covered with 
viscid saliva, but there is no thirst ; the patient is constantly 
chilly ; diarrhoea. 

Rhus fox. — Aching in the limbs, causing great bodily rest- 
lessness; cannot remain quiet in one position ; prostration and 
typhoid symptoms. 



684 DISEASES OF CHILDREN. 

Sanguinaria is often indicated when the rhinitis and phar- 
yngitis are intense. There is fluent coryza, involvement of 
the accessory nasal cavities (sinusitis), dryness of the throat 
with burning, extending down into the oesophagus ; wheezing 
cough. 

During convalescence China is a valuable remedy. It aids 
in restoring the patient's former strength and appetite. Gis- 
erius (Arndt, Practice of Medici7ie) obtained most satisfactory- 
results from its use, in the first decimal dilution, in several 
Berlin epidemics. 

EPIDEMIC CEREBROSPINAL FEVER (MENINGITIS) J SPOTTED 

FEVER. 

As the name implies, this is an inflammatory affection in- 
volving the meninges of the brain and spinal cord and occurs 
epidemically, although sporadic cases are not uncommon, es- 
pecially in localities that have once been the seat of an epi- 
demic. The disease does not appear to be contagious and 
during epidemics the cases occur in irregular distribution,, 
there being no evidence that they are communicated from 
one individual to another. The exciting cause is the diplo- 
coccus intracellularis meningitidis (meningococcus) of Weich- 
selbaum. It must not be forgotten, however, that there are 
other forms of purulent meningitis which often bear a strik- 
ing clinical resemblance to this specific disease. In this con- 
nection, pneumococcns meningitis, which may be primary, de- 
serves special mention, as it has no doubt often been mis- 
taken for cerebro-spinal fever. 

As to the virulence of the meningococcus, this is very 
slight, as Heubner has shown. This explains why this form 
of meningitis is the least fatal, and why epidemics never at- 
tain the numerical strength reached by other infectious dis- 
eases when they break out epidemically. 

The diplococcus meningitidis was discovered in 1888 by 
Weichselbaum and its role as the specific micro-organism in 
the disease is now universally accepted. Morphologically it 



ACUTE INFECTIOUS DISEASES. 6S5 

resembles the gonococcus of Neisser, being biscuit-shaped and 
found within the polynuclear leucocytes. It readily stains 
with Loeffler's methylene blue and decolorizes by Grain's 
method, although not constantly (Jaeger). It is cultivated 
with difficulty, growing best on Loeffler's blood serum at body 
temperature. Weichselbaum is of the belief that the diplo- 
coccus gains access to the brain by way of the nose, ear and 
upper air-passages. This seems plausible, as the organisms 
have been found in the nasal secretion of victims of the dis- 
ease ; also, rhinitis may be one of the early symptoms of 
cerebro-spinal fever. 

The bacteriologic diagnosis is of the greatest prognostic 
importance. Cases of meningitis in which the pneumococ- 
cus is present usually die very rapidly, while those due to the 
diplococcus intracellularis run a more protracted course and 
often recover. The high mortality of some epidemics is 
probably due to the inclusion of many cases caused by 
Fraenkel's organism (Lenhartz). The nasal secretion may 
contain the organism, but the only reliable method of pro- 
cedure is to examine the fluid obtained by lumbar puncture 
(see p. 458). 

Epidemics of cerebro-spinal meningitis occur most fre- 
quently in the winter months. While country districts and 
barracks have been mainly attacked in the past, still our large 
cities are now getting their share of the disease. Children 
are peculiarly susceptible to the disease and it may attack 
young infants. Poverty, overcrowding, physical overexertion 
and even traumatism have been looked upon as predisposing 
causes. 

Pathology. — Rapidly fatal cases show only slight patho- 
logical lesions. On the other hand, fully developed cases 
show all the signs of a severe, purulent meningitis. Some 
cases become protracted and result in thickening of the 
meninges ; degenerative changes iu the cerebral cortex ; 
marked distention of the ventricles. 

The pathological process is an exudative inflammation of 



686 DISEASES OF CHILDREN. 

the pia mater affecting chiefly the base of the brain and the 
posterior surface of the cord. The exudation into the cord 
is most pronounced in the dorsal and lumbar region. Effusion 
into the ventricles and into the pia mater of the cortex co- 
exists to a lesser degree. The cranial nerves are more or less 
involved according to the amount of exudate and pressure 
entering into the case. The exudate is at first sero-fibrinous, 
soon becoming purulent. It is rich in poly nuclear leucocytes. 
Some degree of cerebritis may co-exist. 

Associated lesions that may be encountered .are cutaneous 
haemorrhages (petechias) ; nephritis ; broncho-pneumonia ; 
parenchymatous degeneration of the heart, liver and kidneys ; 
arthritis. 

Symptomatology. — The disease is most irregular in its 
clinical manifestations and may prove fatal within a few 
hours or run a long and protracted course. There are inter- 
mediate cases of moderate severity in which perfect recovery 
takes place. Epidemic cerebrospinal meningitis is the least 
fatal form of meningitis, but unfortunately a larger propor- 
tion of the cases that recover are left with some permanent 
disability such as deafness, blindness, idiocy, paralysis. 

A number of types of cerebro-spinal meningitis are to be 
recognized, the classification being based chiefly upon the 
duration and severity of the symptoms. The invasion, how T - 
ever, shows a general resemblance in all cases. The onset is 
sudden, with either vomiting or convulsions, intense head- 
ache and fever, and soon the most characteristic symptoms of 
the disease, namely, rigidity of the neck muscles and retrac- 
tion of the head, makes its appearance. 

In the fulminating form the onset is so sudden and over- 
whelming that the patient may succumb within a few hours. 

These foudroyant cases usually prove fatal in the first few 
days. Deep coma develops early and is associated with re- 
traction of the head and even opisthotonos. Strumpell 
[Specielle Path. u. Therapie) mentions a class of cases with 
sudden and grave onset, similar to the fulminating form, 



ACUTE INFECTIOUS DISEASES. 687 

which however abort in the course of several days and go on 
to complete recovery (abortive form). Then there are mild 
cases, in which the entire clinical course is marked bv slight 
development of the symptoms, the duration also being shorter 
than usual. 

Protracted cases are not uncommon. The symptoms may 
extend over a period of from two to three months and the 
child ultimately recover. In these protracted cases the fever 
often disappears entirely for days and the other manifesta- 
tions will abate, only to recur with renewed vigor. When 
the fever becomes decidedly intermitting, they are spoken of 
as intermitting cerebrospinal fever (vox Ziemssen). The 
last quoted course is possible, because of the remissions that 
take place in the pathological process, which may be com- 
pared with the repeated relapses observed in cases of rheuma- 
tism pursuing a chronic course (Heubner, Kinderlieilkundc). 
The same author reports the case of a boy who after three 
and a half months of suffering made a complete recovery. 
Emaciation, attaining a marked degree of marasmus, goes 
hand in hand with the progress of the disease. 

The ordinary form runs an average course of from two to 
four weeks. It is so irregular, however, that it is impossible 
to foretell the outcome of any case. While the onset is as a 
rule sudden, still there may be some prodromal manifesta- 
tions — such as malaise, and headache ; slight fever. In in- 
fants, conjunctivitis is not infrequently observed. 

The initial symptoms point to the brain as the seat of the 
affection. They are vomiting or convulsions, sometimes a 
chill ; intense occipital headache and high fever. To these 
symptoms stiffness of the neck is soon added and with the 
outpouring of exudate more or less disturbance of conscious- 
ness is added. 

In infants bulging of the fontanel is to be noted. Delirium 
is a common symptom with older children. Complete stupor 
develops, although often the patient may be aroused, or lucid 
moments will alternate with the stupor. Fever and delirium 



688 DISEASES OF CHILDREN. 

may only be present at night, the child being rational during the 
day and able to sit up in bed and play with its toys (Koplik). 

The headache may be so intense that we will observe the 
child knitting its brows and moaning with pain, while at the 
same time it is so deeply in stupor that we can neither arouse 
it nor get a response. Beside the cerebral manifestations we 
will observe marked hyperesthesia of the cutaneous surface, 
due to the irritation of the posterior nerve roots (spinal) by 
the inflammatory exudate. This hyperesthesia is most 
marked in the lower extremities. 

Retraction of the head occurs earlier (within a day or two 
or even within a few hours) and is more pronounced and 
more persisting in cerebro-spinal fever than in any other 
form of meningitis (Heubner). As a rule, there is tender- 
ness along the entire spine, which may be rigid or arched. 

Disturbances in the functions of the cranial nerves are 
manifested as hyperesthesia of the sensory and irritation of 
the motor nerves. Thus photophobia, tinnitus aurium and 
disturbances of smell are encountered. Optic neuritis may 
develop with consequent blindness, and permanent deafness is 
another of the unfortunate sequelae of the disease. 

Spastic strabismus ; irregular but reacting pupils ; ptosis ; 
spasm of the facial muscles and dysphagia are all to be ob- 
served. In contradistinction to tuberculous meningitis, there 
is more tendency to irritation and less to actual paralysis in 
cerebro-spinal meningitis than in the former. 

The extremities are rigid, the arms usually being flexed 
while the legs are straightened and resist passive movements. 
If, however, we flex the thigh upon the abdomen, or if the 
patient attempts to get up, spasmodic flexion of the leg upon 
the thigh takes place. This phenomenon is known as Ker- 
nig^s sign. It is readily demonstrated by flexing the thigh 
upon the abdomen with the patient in the dorsal position, and 
then attempting to extend the leg out on a line with the 
thigh. The method of obtaining Kernig's sign in cerebro- 
spinal meningitis is shown in Fig. 46 ; ordinarily, however, 



ACUTE INFECTIOUS DISEASES. 689 

the thigh should be flexed to a greater degree than here 
shown, in order to avoid all possibility of error. As the leg 
is lifted up in this manner a spasmodic resistance is en- 
countered, due to contracture of the hamstring muscles. 
Kernig\s sign is present in a large proportion of all cases 
of meningitis, but especially when the meninges of the 
cord are at the same time involved. It indicates irritation 
of the pyramidal tracts; Fraenkel (New York) thinks the 
phenomenon depends upon traction on the cauda equina?, 
and he calls attention to the fact that we often can see the 
Babinski sign take place in the foot simultaneously with 
the occurrence of the Kernig. 

The cutaneous manifestations are important, and we should 
not forget that the disease acquired its old name from the 
petechial rash that is present in about a third of the cases. 
In Osier's cases the rash was common. Fully one-half, if not 
more, present herpes labialis or facialis (Strumpell). 

The /ever does not conform to any regularity of type. It 
usually rises rapidly with the onset of the disease, reaching 
to 102° to 103 ° F., even in the fulminating cases, but the 
temperature does not bear a constant relationship to the 
severity of the case. As Goodno says, " In none of the in- 
fectious fevers is the average temperature as low as it is in 
cerebro-spinal fever, and in none are such remarkable fluctua- 
tions manifested." Cases have been observed in which practi- 
cally no fever was present. The diurnal variations may be of 
wide range and the highest point is not necessarily attained 
in the evening hours, as is usually the case in other infectious 
diseases. The intermitting type resembles pyaemia rather 
than malaria. In the protracted cases the fever may abate 
for several days and then recur with all its former vigor. In 
Osier's experience a sudden fall of temperature is a bad 
omen. 

The pulse may be slow in the beginning, but the charac- 
teristic slowing observed in tuberculous meningitis is not 
encountered. In fulminating cases, however, it may be slow 



690 DISEASES OF CHILDREN. 

and irregular. This is a grave symptom. Usually it is rapid 
and irregular. The respirations show nothing pathognomonic ; 
exceptionally Cheyne-Stokes respiration occurs. 

The blood shows a distinct leucocytosis. 

Complications are observed in some cases, they are more 
common in some epidemics than in others. Aside from the 
complications on the part of the nervous system already re- 
ferred to there may be clonic contractions and paralysis of in- 
dividual extremities and occasionally unilateral paralysis. 
They appear to be due to various pressure conditions by men- 
ingeal exudates or possibly they owe their origin to varia- 
tions in circulatory conditions, but at the autopsy a clear in- 
sight as to what has caused these paralyses is by no means 
always obtained (Eichhorst, Modern Clinical Medicine). 

Pneumonia and arthritis may occur as metastatic inflam- 
mations. The arthritis of cerebro-spinal meningitis closely 
resembles acute articular rheumatism and may be associated 
with endocarditis. 

As sequelae, long-continuing nervous disturbances, such as 
vertigo ; headache ; loss of memory ; neurasthenia are com- 
mon. Permanent deafness, blindness, idiocy and chronic 
hydrocephalus have been referred to. 

Prognosis. — Excepting in the mild and abortive cases the 
prognosis is most grave. Even if the acute symptoms sub- 
side there is the danger of the case becoming protracted and 
running into a fatal marasmus or of one of the unfortunate 
sequelae remaining after recovery. There are few recoveries 
in children under two years (Koplik). In older children the 
mortality is about 40 per cent. (Hirsch). 

Diagnosis. — In fulminating cases that die before the clini- 
cal picture of the disease is developed, it is naturally impos- 
sible to make a diagnosis. When during an epidemic, how- 
ever, a child is seized with fever, vomiting or convulsions 
and rapidly goes into a state of coma, it is fair to surmise 
that we are confronted with a case of cerebro-spinal menin- 
gitis. Should retraction of the head develop, the diagnosis is 



ACUTE INFECTIOUS DISEASES. 691 

almost certain. We must, however, not forget that pneumonia 

may begin precipitately with marked cerebral symptoms. 
Careful exploration of the chest will decide the question 
under these circumstances. When pneumonia complicates 
cerebrospinal meningitis the pulmonary symptoms do not 
develop until later in the disease. 

Osier has called attention to cases of typhoid fever begin- 
ning abruptly with delirium, headache, retraction of the head 
and high fever. Goodno corroborates this observation. If 
such a case dies early, differentiation is impossible unless fluid 
containing the meningococcus can be obtained from the spinal 
canal. 

Differential diagnosis rests mainly between cerebro-spinal 
and tuberculous meningitis. In cerebro-spinal meningitis the 
onset is more sudden ; the fever is higher ; retraction of the 
head occurs earlier and is more marked and the nervous mani- 
festations are more irritative and less inclined to become 
paralytic in nature. The hypersesthesia of the skin and the 
petechial rash when present are strong, confirmatory symp- 
toms. Then again, the presence of an epidemic is to be taken 
into consideration and in the case of tuberculous meningitis 
the family history, the diathesis and the presence of a tuber- 
culous lesion of the lungs, bones or glands are valuable data. 
Lastly, lumbar puncture remains to be mentioned as the most 
positive diagnostic method (see p. 458). 

Posterior Basic Meningitis. — A sporadic form of meningitis, 
simulating tuberculous meningitis in many respects, has been 
shown by Koplik (Amer. Jour, Med. Science, Feb., '05) to be 
clue to the meningococcus (see p. 454, Tuberculous Meningitis). 

Treatment. — The treatment of cerebro-spinal meningitis 
by hot baths has given promising results. They are indicated 
in the beginning of the disease and undoubtedly exert a seda- 
tive effect upon the nervous manifestation. Beginning with 
a temperature of 98 F. the heat can be increased daily by a 
degree, up to 105 F. One bath daily is sufficient, and as little 
handling G f the patient as possible- is to be advised on ac- 



692 DISEASES OF CHILDREN. 

count of the suffering caused thereby. An ice-bag to the 
head sometimes gives relief from the intense headache. 

Of the greatest importance is the feeding of these cases. Ex- 
treme emaciation results unless we take advantage of every 
opportunity of getting sufficient nourishment into the child. 

The removal of the exudate by means of lumbar puncture 
often gives relief both of pain and of the pressure symptoms. 
If exudate is abundant it will prove of benefit to tap the 
spinal canal every two or three days. 

Remedies. — As the symptoms are due to the inflammatory 
process and the presence of the exudate rather than to toxaemia, 
in this respect differing from most of the other infectious dis- 
eases, the remedies that will suggest themselves in the treat- 
ment of cerebro-spinal fever are such as exert a notable in- 
fluence over inflammation. In the early stages Belladonna 
is by far the most valuable remedy, corresponding to the 
meningeal congestion both symptomatically and pathologi- 
cally. As soon as exudation develops, Bryonia, Apis mellifica 
or Cuprum aceticum become indicated. When toxic symp- 
toms predominate over inflammatory, such remedies as 
Hyoscyamus, Opium and Helleborus are more suitable. Cases 
with marked petechial eruption and of protracted character 
call for Arsenicum, the snake venoms, and especially Rhus 
toxicodendron. Cases with convulsions call for Cicuta virosa. 

Actea racemosa is useful for the pains and spasms persist- 
ing after the acute symptoms have subsided (Searxe). 
There is intense occipital headache, like a bolt being driven 
from the nape of the neck to the vertex, felt with every 
pulse-beat ; stiffness of neck ; delirium. 

Apis mellifica. — Sopor, interrupted by piercing shrieks ; 
squinting ; pupils dilated ; retraction of head (stage of effu- 
sion). 

Arsenicum. — Protracted and adynamic cases ; intermittent 
type. 

Belladonna. — High fever; convulsions; flushed face; photo- 
phobia; difficulty in swallowing; intense throbbing headache; 
delirium ; vomiting ; marked drowsiness. 



ACUTE INFECTIOUS DISEASES. 693 

Bryonia. — Bursting headache ; apathy ; child cries when 
it is touched or moved ; arthritis or pneumonia. 

Camphora. — Fulminating cases with collapsic symptoms. 

Cicnta. — The toxicologic reports of this remedy show its 
pronounced action upon the meninges of the brain and cord, 
in which it sets up intense congestion with resulting con- 
vulsions. Various forms of paralysis may follow upon the 
convulsions. More or less disturbance of consciousness is as- 
sociated. Dr. Baker (Trans. New York Horn. Soc, 1872) 
reported most promising results from Cicnta after using it in 
an epidemic at Batavia, New York. 

Cuprum aceticum has long been recognized as a potent rem- 
edy in meningitis, and was used with success by Dr. George 
Schmidt, of Vienna, for the cerebral symptoms accompanying 
the infectious diseases. Goodno considers Cuprum aceticum 
the most generally useful remedy in cerebro-spinal meningitis, 
giving it the preference over Cicuta when cerebral symptoms 
predominate over the convulsive symptoms. Crotalus has 
been recommended in cases with marked blood changes. 

Gelsemium. — Early stages, chilliness, aching and prostra- 
tion, photophobia, ptosis and squinting; occipital headache, 
with muscular soreness in the neck ; remitting fever. 

Helleborus. — Stupefaction, child bores its head into the pil- 
low; suppression of urine, convulsions (serous effusion). 

Hyoscyamus. — Muttering or wild delirium, unconscious- 
ness, convulsions, pupils dilated, purplish rash. 

Kali hydrojod. — Iodide of potash is the remedy chiefly re- 
lied upon by the old school. There are some encouraging- 
reports from its use, and it may be tried with advantage in 
cases not presenting marked symptoms for another remedy. 

Opium. — Deep coma, pupils fixed, stertorous breathing, 
pulse irregular, inclined to be slow, clammy skin. 

Rhus toxicodendron. — Petechial form, patient restless, pro- 
foundly prostrated ; herpetic and purpuric eruptions, intense 
aching pains in back and extremities, tongue dry and brown 
with reddish tip. 



694 DISEASES OF CHILDREN. 

Veratrum viride. — Fulminating cases with convulsions, 
furious delirium, intense cerebral congestion and splitting 
headache, vomiting, double vision, numbness of limbs and 
flying pains ; pneumonia. 

Some of the sequelcz may be relieved by the following 
remedies : 

Neurasthenia, loss of memory, vertigo — Argentum nitricum, 
Cannabis Indica, Cocculus. 

Neuralgia — Actea racemosa, Gelsemium, Zinc. phos. 

Ocular symptoms — Gelsemium (serous choroiditis, paralytic 
squint), Phosphorus (optic neuritis), Strychnia. 

The deafness following cerebro-spinal meningitis is usually 
looked upon as hopeless, but Dr. Searle, of Brooklyn, has re- 
ported good results from the use of Silica and Sulphur. 

Diphtheria antitoxin has been recommended recently by a 
number of writers, but the results have in no way been uni- 
form. Peabody {New York Med. Record, May 13, '05) tried 
this form of treatment in twenty-two cases, with a resulting 
mortality of 50 per cent. He says: "It is fair to assure you 
that there has not seemed to any of us who have watched 
these cases any influence for good or evil to be ascribed to 
the treatment of them by diphtheria antitoxin." 

malaria; malarial FEVER. 

Malaria represents a group of febrile affections resulting 
from infection with micro-organisms belonging to the class of 
protozoa. Bach type of malarial fever is traceable to a dis- 
tinct variety of micro-organism, possessing its own morpho- 
logical and biological peculiarities. There is a specific para- 
site for tertian intermittent fever, for quartan intermittent 
fever, and for aestivo-autumnal fever, or tropical malaria. 
These parasites attack the red blood-corpuscles, in which they 
live and develop to full maturity and sporulation. With the 
completion of sporulation a malarial paroxysm is always ob- 
served. The tertian organism requires forty-eight hours to 
undergo a complete developmental cycle ; consequently a pa- 



ACUTE INFECTIOUS DISEASES. 695 

tient infected with this parasite will experience a paroxysm 
every third day, i. e., with the occurrence of spornlation. In- 
fection with the quartan parasite results in a paroxysm occur- 
ring every fourth day. Double infection with the tertian 
parasite, each group maturing on separate days, results in 
daily paroxysms. This is the most frequent type in the acute 
intermittent fevers in this latitude (Osler). Quartan fever 
is extremely rare in this country. This parasite may be pres- 
ent in the blood coincidently with the tertian parasite. By 
such a combination most puzzling types of fever are produced. 
The parasite of sestivo-autumnal fever is smaller than the 
other types of parasite, and is practically confined to the 
Southern States in this country. 

The disease prevails endemically in certain localities, which 
are known as malarial regions. Although low, swampy and 
poorly drained regions and the banks of sluggish streams are 
the most frequent localities for malaria, still it also exists in 
many of the larger cities, especially in their suburbs and 
along the river fronts. The disease is conveyed to man 
by the sting of the mosquito, the genus anopheles being the 
one capable of acting as a host for this parasite. Malaria has 
no doubt increased in the northern cities since the influx of 
laborers from the South and from Italy has grown to such 
proportions. 

The pathological changes resulting from malarial infection 
are intense anaemia, due to destruction of the red corpuscles 
by the parasite; enlargement of the spleen, which may lead 
to hyperplasia of the same ; pigmentation in the liver, kid- 
neys and brain. In cases which have resulted fatally there 
may be intense pulmonary congestion or pneumonia ; ne- 
phritis ; gastroenteritis. Fortunately, fatal cases are rave, 
the pernicious form of malarial fever being quite uncommon 
in this locality. 

Symptomatology. — A typical malarial paroxysm, consist- 
ing of three well-defined stages, namely, chill, lexer, and 
sweat, is seldom seen in children under six years of age. 



696 DISEASES OF CHILDREN. 

Both the first and third stages may be absent or but poorly 
denned. Instead of a chill there may be only the signs of a 
vasomotor spasm, such as blueness of the finger-nails, cyano- 
sis of the face, cold extremities and yawning, or there may 
be vomiting, diarrhoea and even convulsions or a comatose 
state preceding the accession of fever. In the course of an 
hour or less the fever rises rapidly and may attain to an 
alarming height. This condition of hyperpyrexia lasts for 
an hour or two, ending by a gradual fall. Sweat may be en- 
tirely absent after the fever. Instead of even this attempt to 
simulate a malarial paroxysm as it occurs in the adult, the case 
may assume more of a remitting type. Holt observed convul- 
sions ushering in the attack in four instances, and in two- 
thirds of his cases there was vomiting. Sheffield (JV. Y. Med. 
Jour., Oct. 23, 1897) reports a series of cases occurring in 
New York City, the average age of which was ten years, 
and in one- third of these the chill was absent. In twenty- 
one cases there were fifteen of the quotidian type, four 
tertian, one tertian and quotidian (mixed), and one quartan 
and quotidian. 

When there is a complete remission of fever the child may 
appear well until the second paroxysm makes its appearance. 
As these attacks return they become more and more atypical, 
and the condition may go over into one of a remitting type 
of fever. If this continues uninterruptedly, grave constitu- 
tional symptoms develop, such as prostration ; heavily coated 
tongue ; abdominal tenderness ; slight jaundice. This is fre- 
quently called typho-malarial fever, but there are no grounds 
for supposing such a condition to be dependent upon a mixed 
infection with the bacillus of typhoid fever and the parasite 
of malaria. 

Enlargement of the spleen and anaemia are usually well 
marked, especially if the disease has progressed to any 
considerable extent. The symptoms accompanying the 
febrile stage are those common to febrile disturbances in 
general. 



ACUTE INFECTIOUS DISEASES. 697 

The prognosis is usually good. Untreated cases may take 
one of the following courses : (i) mild cases may go on to 
spontaneous recovery; (2) the paroxysm may gradually 
diminish in intensity, but grave anaemia and chronic cachexia 
develop, or (3) the paroxysm may increase in severity and 
assume finally a pernicious type (Thayer, Lectures on Ma- 
larial Fever, 1897). 

Masked or Irregular Forms of Malaria and Malarial Ca- 
chexia. — Malaria is seen in its masked form more frequently 
in children than in adults, and a malarial paroxysm may be 
so atypical, or affect a certain region to such a degree, as to 
entirely mask the condition, the malarial element only being 
eventually suspected by the regularity of recurrence of the 
attack, the association of enlarged spleen and anaemia, and 
possibly by a history of exposure to malarial infection or resi- 
dence in a malarial district. Finally, the discovery of the 
parasite in the blood expels all doubt as to the true nature of 
the case. 

Disturbances in the nervous system are common. Head- 
ache, continuous or recurring ; neuralgia in various local- 
ities ; intermittent spasmodic torticollis, accompanied by 
a slight rise in temperature and enlarged spleen (Holt) ; 
multiple neuritis. Trigeminal neuralgia is rare in children. 
Congestion of the lungs, simulating pneumonia, may occur 
paroxysmally. 

Malarial cachexia may develop likewise without malaria 
having been suspected, either from the attacks being unac- 
companied by very high fever, or from presenting themselves 
in a masked form. The child is markedly anaemic and 
emaciated, the skin being dry and sallow. The face has a 
drawn, pinched look, and the eyes are surrounded by dark 
circles. Indigestion and diarrhoea, irregular febrile move- 
ments and enlargement of the spleen are usually present. 
Here, again, an examination of the blood will corroborate the 
diagnosis. The prognosis in such cases is not as favorable as 
in fresh febrile attacks. 
45 




698 DISEASES OF CHILDREN. 

Diagnosis. — Malarial infection should always be suspected 
when a periodic disturbance, accompanied by anaemia and en- 
largement of the spleen, is encountered. In order to remove 
all question of doubt, a blood examination should be made. 
A negative result does not necessarily exclude malaria, as it 
may require several examinations in order to find the Plas- 
modium. Even in the absence of the plasmodium a leuco- 
paenia together with an increase in the large mononuclear 
leucocytes is pathognomonic of malarial infection (see p. 419). 

Ancemia infantum pseudo-leukcsmia presents some of the 
symptoms of malarial cachexia, but the absence of fever, the 
leucocytosis and absence of the malarial parasite readily dif- 
ferentiate the two conditions. 

The remittent form of malarial fever is frequently con- 
founded with such conditions as the hectic fever of tubercu- 
losis ; typhoid fever, and the septic fever of empyema, pyelitis, 
etc. A careful process of exclusion is therefore necessary in 
order to justify a diagnosis of malaria in many instances. I 
would especially warn against neglecting to make a most 
thorough examination of the chest, as I have seen sacculated 
empyema simulate intermitting malarial fever as well as the 
remitting type. Here leucocytosis is also present, as a rule. 
The old school attaches great importance to the therapeutic 
test, i. e., improvement of symptoms upon the administration 
of Quinine and in doubtful cases this is justifiable. 

Treatment. — Little can be done for the patient during a 
paroxysm to render him comfortable, but fortunately its 
duration is not long enough to cause material harm. During 
the interval and during convalescence a tonic treatment is in- 
dicated. Cases simulating typhoid fever are to be managed 
on the same general 'principles applying to such cases. 

Remedies prescribed in malarial fevers are usually divided 
into three classes : (a) those possessing a specific and abortive 
influence over the paroxysms, (b) those indicated for general 
disturbances arising during and complicating the paroxysm, 
(c) those indicated in the chronic form and for the cachectic 
manifestations. 



ACUTE INFECTIOUS DISEASES. 699 

To the first class Cinchona and its alkaloid, Quinine, be- 
long pre-eminently. We must all admit its specific action in 
typical cases of malarial fever ; and while it is, in general, 
overestimated and given far too heroically, still it remains the 
most important remedy for the disease. I have, however, en- 
countered a number of cases in my practice that were not 
cured by Quinine and which were promptly relieved by a 
remedy selected purely symptomatically. 

The true sphere of Cinchona lies in that class of cases which 
presents each stage well marked, with the absence of any com- 
plications or symptoms not directly traceable to the febrile 
paroxysm. Chininum sulph. is supposed to exhibit greater 
regularity in the time of occurrence of the paroxysm, besides 
possessing some symptoms not found under Cinchona. For a 
fuller description of these remedies and their special indica- 
tions in intermittent fever I must refer to Allen's Therapeutics 
of Intermittent Fever. As to the dose, that is unfortunately 
a matter of. contention. Kafka {Homceopatische Therapie) 
sums up his experience as follows : " Given on exact indica- 
tions, Quinine acts in small as well as in larger doses, but 
not in infinitesimal doses. While the most beautiful results 
were attained with the ix trituration, or even stronger doses 
of one to two grains given every two hours during the period 
of apyrexia, we exerted ourselves in vain with the 2d, 3d, 
etc." Goodno {Practice of Medicine) expresses similar views 
and he recommends the usual therapeutic dose. 

The other remedies, aside from Cinchona and its alkaloid, 
that have occasionally given me positive results are Nux 
vomica, Eupatorium perfoliatum, Ipecacuanha and Xatrum 
muriaticuni. 

If strong indications for any one of these remedies are 
present in a case I give it before prescribing Qui nine. 

Remitting malarial fever suggests Gelsemiutn^ Baptisia and 
( liininum arscnicosum. 

In malarial cachexia . \rscnicuni is the most important 
remedy. 



700 DISEASES OF CHILDREN. 



TYPHOID FEVER. 



Typhoid fever is an acute infectious disease, the specific 
causative agent being the bacillus of Eberth. This germ is 
found abundantly in the discharges from the bowels ; also in 
Peyer's patches, the mesenteric glands and in the spleen. The 
bacilli have also been demonstrated in the circulating blood 
and in the urine when there was albuminuria. The anatom- 
ical lesions are inflammation of Peyer's patches and of the 
solitary follicles in the ileo-csecal region with tendency to 
ulceration and enlargement of the spleen. A maculo-papular 
eruption of rose-colored spots appearing mainly upon the ab- 
domen is one of the pathognomonic signs of typhoid fever, 
but like ulcerative lesions of the intestines it is not so con- 
stantly associated with the disease in children as in adults. 
The typhoid bacilli have been demonstrated in these spots. 
The accompanying symptoms are fever of a characteristic 
type ; prostration and disturbances in the nervous system \ 
more or less diarrhoea and wasting. Here again it is not as 
typical as in adults. The fever is more irregular, remissions 
are more pronounced and the duration is shorter, as a rule. 
On account of the absence of pronounced ulceration of the 
bowel in the second week, the temperature does not show the 
septic course assumed in adults at this time. This condition, 
however, is not to be absolutely excluded. The associated 
symptoms are usually milder and diarrhoea may not appear 
until in the later stages of the disease. There is, on the other 
hand, a severe type of typhoid fever occurring in chil- 
dren that may present every unfavorable phase of the disease 
as it is encountered in the adult, not barring copious haemor- 
rhages and perforation of the bowels, but as a rule the grav- 
ity of these cases depends more upon the degree of toxaemia 
than upon anatomical lesions. 

It is only in recent years that the fact of typhoid fever be- 
ing a common disease during childhood has been recognized. 
Many mild cases were looked upon as a simple continued 



ACUTE INFECTIOUS DISEASES. 701 

fever, while more pronounced ones received the appellation 
infantile remittent fever, or they were diagnosticated worm 
fever. Some confusion as to the gravity of the disease is 
still to be detected in the deliberations upon the subject. There 
are several factors influencing an opinion on this question 
that must be taken into consideration. In the first place, we 
must bear in mind that there are two varieties of the disease, 
the mild and the severe type, and the difference between the 
two is so great that West (" Lectures on the Diseases of In- 
fancy and Childhood ") ventured to divide his discourse on 
typhoid fever in children into a separate consideration of 
these varieties. One is therefore likely to judge the disease 
from which ever variety he has mainly encountered. Again, 
mortality reports fiom hospitals and from private practice 
are much at variance because such cases as are brought to a 
hospital are usually critically ill and come from the poorer 
classes, where neglect and poverty have undermined the con- 
stitution. 

The typhoid bacillus is a rod about i-/^ to yn in length by 
0.5-/J to 0.8-/U- in diameter. The ends are rounded. Any of 
the ordinary anilin dyes will stain it, and decolorization takes 
place with Oram's method. Vacuoles and highly refractive 
bodies at either extremity are observed in bacilli grown on 
culture media. The vacules do not stain ; they represent 
retrograde changes. One of the peculiarities of the bacillus 
is its motility, which is destroyed by the blood serum of a 
patient suffering with typhoid fever. The serum also causes 
agglutination and clumping of the bacilli, indicating that an 
antitoxic substance has been produced in the blood of the 
infected person. This is the Widal reaction and it may per- 
sist for several years after the attack, /. c.^ until the immunity 
runs out. It may be observed as early as the sixth day, but 
usually not before the eighth. 

Typhoid fever is a metastatic infection, the bacilli being 
distributed in groups throughout the body. Beside giving 
rise to the lesions seated in the solitary follicles, Peyer's 






702 DISEASES OF CHILDREN. 

patches, mesenteric glands and spleen, the typhoid bacil- 
lus may also produce pneumonia, meningitis, osteomyelitis, 
pleural effusion. Under certain conditions it also acts as a 
pus producer, giving rise to abscess of the spleen and liver. 
As a rule, however, complications are due to an admixture of 
other bacteria, the commonest mixed infections being with 
the streptococcus, staphylococcus and pneumococcus. 

Infection takes place through the alimentary tract. The 
commonest source of infection is drinking water that has been 
contaminated with the dejecta of typhoid fever patients. 

Milk is a common carrier of the infection. As the bacilli 
grow rapidly in milk, the adulteration of this commodity with 
contaminated water becomes a grave matter. The possibility 
of the germ entering the system through the inspired air 
and the occurrence of some cases by direct transmission from 
one patient to another is not to be denied, but such cases 
must be extremely rare. Henoch has seen patients lying be- 
side children with typhoid fever, who discharged their stools 
directly into the bed, contract the disease, and similar cases 
of house infection have been reported from the Children's 
Hospital in Basel, by Hagenbach-Burckhardt and by others. 
The degree of contagiousness, however, is so slight that it 
need not be taken into consideration when any degree of san- 
itary precaution is exercised. 

Typhoid fever is rarely encountered before the second year, 
but there is no doubt that it does occur during infancy. A 
number of authentic cases are on record, and I have person- 
ally encountered it. In two reported epidemics of wide dis- 
tribution i per cent, of the cases occurred in infants under 
two years old. Samuels {New York Med. Journal^ July 28, 
1900) reports a case in a child eighteen months old; the diag- 
nosis was verified by the Widal reaction and the finding of 
Eberth's bacillus in the stools. The fever continued for 
twenty days. There was no rash or diarrhoea. Recently I 
saw a case in an infant one year old with Dr. Bellville. 
There were rose spots, diarrhoea, enlarged spleen, continued 






ACUTE INFECTIOUS DISEASES. 703 

fever, lasting twenty-one days. The Widal reaction was pres- 
ent. Among ninety-seven cases observed by Henoch two 
were in infants under one year ; twenty-one from the second 
to fifth year; fifty-nine from the fifth to tenth year. Yon 
Steffens found among one hundred and forty-eight cases 
two under one year (Baginsky). The majority of cases are 
seen after the sixth year. Boys are more frequently attacked 
than girls. Epidemics are more prevalent in the fail than 
at other seasons. In this climate September and October 
furnish the largest number of cases, although in many large 
cities the disease is practically endemic. In some epidemics 
children are more affected than adults, as occurred here in 
a recent spring epidemic. 

Pathology. — The pathologic lesions are not as marked 
as in the adult for anatomical reasons. The first change 
observed in the intestines is a catarrhal inflammation of the 
lower portion of the ileum, together with swelling of the soli- 
tary follicles -and Peyer's patches in the ileo-csecal region. 
The caecum and colon are moderately involved in the catar- 
rhal inflammation. 

As the process continues round-cell infiltration into the 
lymphoid structure constituting the swollen follicles and 
patches takes place, with the formation of elevated placques 
and shot-like projections. The amount of infiltration, how- 
ever, seldom attains to the degree observed in the adult, and, 
instead of necrosis from compression of the blood-vessels sup- 
plying the affected area setting in, it usually terminates by 
fatty degeneration and resorption of the infiltration. For this 
reason the course is shorter and more benign, and ulceration 
of the bowels is much rarer than in adults. In older children, 
however, the same lesions are to be found that characterize 
typhoid fever in adults. With the breaking down of the in- 
filtrated areas, deep oval ulcers, their long axis corresponding 
to the direction of the bowel, are found. Smaller, irregularly- 
scattered ulcers result with the breaking down of the solitary 
follicles. The slough is more frequently superficial, separat- 



704 DISEASES OF CHILDREN. 

ing without the production of a deep ulcer and unattended by 
the septic fever observed in adults at this stage. Grave 
symptoms are more frequently dependent upon toxaemia than 
upon anatomical lesions. General infection without localiza- 
tion is also possible. 

The changes found in other parts are swelling of the mes- 
enteric glands, swelling of the spleen, which is soft and 
pulpy ; parenchymatous degeneration of the heart, liver and 
kidneys. Hypostatic pneumonia, bronchitis of the finer tubes 
and broncho-pneumonia are commonly associated with ty- 
phoid fever. These lesions are usually due to a secondary 
infection, the typhoid bacillus only rarely producing them 
(see above). Slight pathological changes in the kidneys are 
common, and severe lesions may occur. Bacilli are present 
in the urine in about 20 per cent, of cases during the third 
and fourth week (Park), and the urine may become cloudy 
from their presence. 

Symptomatology. — The onset of typhoid fever is gradual 
in the majority of cases, being preceded for a day or two by 
prodromal manifestation, such as general malaise ; headache ; 
restless and dream-disturbed sleep ; anorexia and constipation. 
There may be slight chilliness recurring for several days, but 
rarely a decided initial chill. The temperature now begins 
to rise in a characteristic manner. Morning remissions are 
marked, but the fever rapidly reaches its acme, usually in 
from four to five days ; in adults this is not attained until the 
end of the first week, and there is a more gradual step-like 
rise in the temperature. 

At times the temperature rises abruptly instead of ascend- 
ing gradually. This is more common in children than in 
adults. The temperature soon reaches its maximum evening 
rise (103 to 104 F.) and by the end of the second week a 
rapid decline in the temperature is the rule in such cases. 
On the other hand, an abrupt beginning with a high fever 
(105 ) and early delirium is characteristic of the gravest (ful- 
minating) form of the disease, namely, acute typhoid septi- 



ACUTE INFECTIOUS DISEASES. 



'05 



ccemia, and it may not be possible to decide at once whether 
this type or a milder type with a complication (pulmonary) 
is confronting us. After the acme has been attained the fever 
presents a continuous remitting type. The remission occurs 
in the morning, and the exacerbation in the evening ; in 
severe forms, with high temperature, the remissions are not 
as marked as in milder cases. This is a sign of prognostic 
importance (see "Prognosis"). Toward the end of the sec- 
ond w r eek (about the twelfth day) the morning remission be- 




tayo/Dis. 



FIG. 59. — TEMPERATURE CHART FROM A CASE OF TYPHOID FEVER 

IX A CHIM) FOUR VICARS OI,I), ILLUSTRATING RAPID 

ONSET AM) SHORT COURSE. 



comes more pronounced, and soon a lowering in the evening 
rise is noticed. The temperature now falls by lysis, and in 
the course of from a few days to a week the stage of de- 
ferescence is completed. Accordingly, a typical, uncompli- 
cated case of moderate severity occurring in a child under ten 
years old pursues a course of from fifteen to nineteen days. 
Severe cases, or such in which complications occur, may be 
indefinitely prolonged beyond this period, or prove fatal. 



706 DISEASES OF CHILDREN. 

The age of the child also exerts an influence upon the dura- 
tion of the fever. In children of five years the average dura- 
tion is 15.7 days ; at eight years, 18.3 days, and at ten years, 
20.3 days (Montmollin). 

The symptoms occurring during the first stage are fever, 
accompanied by prostration, gastric derangement and marked 
indifference. The face is pale, and the cheeks usually 
flushed ; later, the countenance wears a characteristic apa- 
thetic expression, and assumes a sub-cyanotic color, due to 
the impaired surface circulation. 

The temperature is not always an index of the severity of 
the infection. While abrupt onset with early hyperpyrexia 
indicates an intense infection, still a weak heart and low 
vitality may be the reason for failure to react against the dis- 
ease and consequently we may have most serious cases with 
but moderately high fever. Cases are on record in which no 
rise of temperature occurred, and still grave symptoms were 
present. Jacobi {Pediat7'ics, Dec, 1899) believes that the 
very severe typhoids that exhibit bad cerebral symptoms are 
likely to have low temperatures on account of the thorough 
sepsis prevailing. In such the prognosis is bad. A sudden 
rise of temperature during the course of the fever usually in- 
dicates a complication, while a sudden fall means haemor- 
rhage or perforation. 

The tongue is heavily coated with a light-yellowish fur. 
This coating wears off in places exposing the slightly swollen 
papillae as red specks. A red streak down the centre is like- 
wise produced by the tongue rubbing against the upper cen- 
tral incisors during its propulsion. Only in severe and pro- 
tracted cases does the tongue become brown and cracked. 
Even when the lips are covered with brown crusts and cracked 
and bleeding, the tongue is often more or less moist and light 
in color. 

Cracking and bleeding of the lips is common in children, 
from the great prevalence among them of picking at the 
same. The mouth is dry, the tongue being heavily coated, 



ACUTE INFECTIOUS DISEASES. 70 i 

and the breath offensive. Aphthae and thrush do not appear 
nearly so frequently in typhoid as in ilec-eolitis. 

The bowelsare usually constipated in the beginning,but they 
may become loose as the fever progresses. In cases marked by 
severe bowel symptoms the stools are thin and water}-; often 
involuntary. The abdomen is prominent, and tenderness and 
gurgling are found in the right iliac fossa upon pressure. 
This is due to the accumulation of fluid in the lower ileum 
and may be present even when there is constipation. In in- 
fants there is considerable mucus in the stools and they con- 
form more to the type found in an ordinary catarrhal in- 
flammation. Gas forms plentifully, but owing to the paretic 
condition of the gut it is not readily expelled. The typical 
typhoid stool is of a dirty, yellow color and thin, even consist- 
ency, being appropriately described as the u pea-soup stool." 
It has a characteristic penetrating offensive odor, which may 
cling stubbornly to the patient. During the second week 
when delirium sets in the stool is usually involuntary ; this 
condition may remain to the end in adynamic cases. 

The eruption is not so constant and is less abundant in 
young children than in adults ; it is found upon the abdo- 
men and lower portion of the chest, developing in crops. It 
is absent in perhaps 20 per cent, of cases (Jacobi). The first 
crop appears about the eighth day, successive crops appearing 
for a week or longer. The spots consist of small, rose-colored 
macules, disappearing on pressure. They may spread to the 
neck and lower extremities, and in serious cases with septic 
infection petechias may develop. In Dr. Bellville's case, an 
infant one year old, the spots were on the neck and face as 
well as on the abdomen and chest. 

The spleeji becomes enlarged early in the disease ; in fact, 
by the end of the first week it can usually be felt at the 
border of the ribs. It may serve as an index to the progress 
of the disease, its return to normal size during the middle of 
the third week auguring a good prognosis. If it fails to di- 
mmish in size there will be a relapse (Jacobi). 




708 DISEASES OF CHILDREN. 

The pulse furnishes valuable data for diagnosis early in the 
disease. Instead of rising progressively with the temperature 
during the first week of the fever, it remains slow and meas- 
ured. With the progress of the fever, however, it becomes 
rapid and feeble. We should, therefore, always suspect enteric 
fever whenever a febrile condition is encountered in children 
in association with a relatively slow pulse-rate in the early 
stage. The opposite condition holds good in meningitis. The 
dicrotic pulse, so characteristic in adults, is observed only in 
older children. 

The disturbances of the nervous system are apathy, pros- 
tration and cerebral irritability. The child is often exceed- 
ingly cross and slow in answering questions and obeying 
requests. Delirium is usually present, especially during 
the night, and if the child is particularly susceptible to 
the typhoid poison, symptoms resembling meningitis may 
develop. Thus, dilated pupils, retraction of the head, 
twitching of the muscles of the face and extremities, crying 
out in sleep and stupor are frequently encountered. They 
disappear with the fall in the temperature. The toxic irrita- 
tion of the brain sometimes produces choreiform movements, 
such as are observed in chorea gravis. The prognosis is grave 
in these cases. A true cerebro-spinal meningitis may compli- 
cate typhoid fever in rare instances. 

The urine may become albuminous from acute parenchy- 
matous degeneration of the kidneys. The bacillus is usually 
present in the urine in such cases, which probably accounts 
for the albuminuria. Actual nephritis is rare. 

The blood undergoes no important changes in the early 
stages of the disease, but by the third week a decided anaemia 
has developed, due to a reduction both in the number of red 
corpuscles and in the amount of haemoglobin (Thayer). 
Leucocytosis does not appear unless perforation or secondary 
infection occurs. 

Besides the rose-spots, sudamina frequently develop upon 
the skin, mainly on the chest and abdomen. They appear in 



ACUTE INFECTIOUS DISEASES. 709 

the later stages of the disease. At this period profuse and 
debilitating sweats may occur, with subnormal temperature. 
The patient seems collapsed after the sweats, but I have never 
seen cause for alarm from this condition, although a stimulant 
is generally necessary to bring the temperature back to nor- 
mal. It is quite customary to find a subnormal morning tem- 
perature continuing for some time during convalescence. 

Bed-sores, boils, phlebitis and abscesses in various parts are 
seen in septic cases and in the debilitated. 

Abortive Type. — Instead of running its full course typhoid 
fever may abort at any stage. Such a case begins as an or- 
dinary attack and there may be all of the characteristic symp- 
toms, i. e., nosebleed; ascending fever ; iliac tenderness; dry, 
coated tongue and rose spots, but by the tenth or twelfth 
day the temperature will have returned to normal and conva- 
lescence be in progress. Formerly the term, simple continued 
fever was applied to this class of cases, but it is doubtful if 
a continued fever occurs without an infective agent. I have 
obtained the Widal reaction in most of my cases of this class 
going beyond eight days. 

Relapses. — These may be said to occur in about 10 per 
cent, of cases. They usually occur during the first two weeks 
of convalescence, but a sudden rise in the temperature and a 
return to the original fever curve, together with the reappear- 
ance of symptoms, may set in during the latter part of the 
third week before the evening temperature has yet become 
normal. A relapse indicates a reinfection with germs 
that have escaped destruction and it is accompanied by the 
symptoms of the original attack. A fresh crop of rose spots 
usually appears. The average duration is from ten to fourteen 
days. The symptoms are usually mild, but death may occur 
during a relapse. This is often the case when a relapse is 
brought on by a premature return to solid food. Baginsky 
believes children to be especially prone to relapses. I believe 
them to be more frequent in certain epidemics. 

Among the complications, bronchitis and broncho-pneu- 



710 DISEASES OF CHILDREN. 

monia are the most frequent. Bronchitis is almost a constant 
accompaniment of typhoid fever. Broncho-pneumonia is not 
uncommon ; this complication is a frequent immediate cause 
of death in the grave types of the disease. A lobar pneumonia 
may also complicate typhoid fever. This may be due to a 
mixed infection with the pneumococcus or it may be due pri- 
marily to the typhoid bacillus. While not altogether char- 
acteristic, still in this form of pneumonia, as a rule, the 
hsemorrhagic element of the pulmonary consolidation is 
prominent. The sputum is also markedly haemorrhagic, not 
unlike that observed in pulmonary infarct. In one of my 
cases of typhoid fever there developed during the second 
week a large area of pulmonary consolidation, and there was 
a copious, deep-red, jelly-like expectoration. This expectora- 
tion contained typhoid bacilli in large numbers. Sappington 
{Hahnemajin Hospital Bulletin, Dec, 1905) reports a typical 
case of typhoid pneumonia in a child seven years old in which 
the diagnosis was verified by post-mortem blood cultures. 
He calls attention to the fact that in these cases leucopaenia 
is more likely to be present than a leucocytosis, even when , 
the pneumonic process is due to a secondary infection of the 
lungs with the pneumococcus. Otitis media ; bedsores ; cir- 
cumscribed suppurative processes; phlebitis and intestinal 
hemorrhages are occasionally seen. Fatal haemorrhages and 
perforation are rare, but perhaps not so rare as is generally 
supposed. Abscess of the lung, empyema and septic parotitis 
are also among the rare complications, usually seen only in 
hospital practice. They are almost always fatal. 

Hemorrhage occurs most frequently during the third week. 
Its indications are collapse and a rapid fall of the temperature. 
Death may occur before blood is expelled. Perforation is less 
common than haemorrhage and presents the most serious of 
all accidents. Characteristically it is preceded by sharp ab- 
dominal pain followed by collapse, and usually intestinal 
haemorrhage. The condition, however, may be masked and 
not suspected until peritonitis develops. 



ACUTE INFECTIOUS DISEASES. 



11 



Other conditions that have been found associated are ulcer- 
ation of the mouth, throat, and genitals ; peri- and endo- 
carditis ; peritonitis ; suppurative synovitis and osteitis ; ne- 
phritis ; tuberculosis. 

SequelcE affecting the nervous system are transitory aphasia ; 
multiple neuritis ; chorea and insanity, all fortunately rare. 

Prognosis. — The prognosis is, on the whole, more favorable 
in children than in adults. Perhaps the chief reason for this 
is the average shorter duration of the fever, the greater toler- 
ance on the part of the heart and the lesser liability of severe 
haemorrhage and intestinal perforation, but we must bear in 
mind that the previous health of the child and the develop- 
ment of one of the graver complications must be carefully 
considered in estimating the prognosis. In young infants 
the prognosis is grave. The mortality rate is not very uni- 
form, thus Holt has placed it at 5.4 per cent; Steffen at 6.7 
per cent.; Henoch at 7.5 per cent, and Baginsky at 9 per cent. 
Judging from my own experience and from observation of the 
practice of my colleagues it is considerably lower under ho- 
moeopathic treatment combined with rational hydrotherapy. 

The age is an important factor; the intermediate ages are 
the most favorable (Roemheld). I recall hearing an emi- 
nent clinician remark at the bedside of a child nine years old, 
" It is, indeed, fortunate to have typhoid fever when you 
are nine years of age." The pulse and temperature are ordi- 
narily a safe guide, but as stated above the amount of fever 
does not always indicate the degree of infection. It is, there- 
fore, best to go direct to the heart, ausculating daily to ascer- 
tain the condition of the heart muscle. When the pulse-rate 
remains relatively low in comparison with the fever and its 
volume is good there is no immediate danger to be feared. A 
rapid pulse, especially when this occurs early in the disease, 
is an unfavorable omen. 

Regarding the temperature, the absolute height of the lexer 
in uncomplicated cases is of prime prognostic importance. 
"With every day that the temperature retains its high range 




712 DISEASES OF CHILDREN. 

without interruption the danger to the patient grows." 
(KeEmperER). We can usually judge of the course that the 
fever is about to run after we have observed the case up to 
the end of the first week. It is rare for the temperature 
to rise above the point attained at this time. The duration 
of the fever in cases of abrupt onset with high fever is, as a 
rule, short. This does not, however, apply to fulminating 
typhoid (see above). The daily variations in the fever are 
also important prognostic points ; the greater the daily remis- 
sions, the less destructive to the organism will be the fever, 
while a continuously high fever with but slight diurnal vari- 
ation, and one that is not influenced by baths, etc., offers an 
unfavorable prognosis (KeEmperER, Modern Clinical Medi- 
cine, 1905). 

Complications, such as pneumonia, septic infection, haemor- 
rhage and tympanitis, always render the prognosis more un- 
favorable. In the fatal cases coming under my notice there 
was present, as a rule, a grave secondary infectious condition, • 
such as septic parotitis, empyema, pulmonary abscess and 
osteomy-elitis. Acute typhoid septicaemia is also fatal in the 
majority of instances. Geohegan [Trans. Amer. Institute of 
Horn, 1897) reports a fatal case from perforation and haemorr- 
hage in a child under two and a half years old. Ratier, of Paris> 
reports twenty-two cases of haemorrhages in a series of seven 
hundred and sixty-two cases, ten of which resulted fatally. 

Diagnosis. — Aside from the pathognomonic symptoms of 
typhoid fever, viz., continued fever of a definite type, rose- 
colored spots, tympanitis with gurgling and tenderness in the 
right iliac fossa, enlarged spleen and pea-soup stools, there is 
at our command the blood test of Widal and the urinary test 
(diazo-reaction) of Ehrlich. Unfortunately for the general 
practitioner, the former is difficult to carry out, requiring spe- 
cial laboratory facilities and expert technique in bacteriology. 
In every large city : however, there are pathological laboratories 
where this test can be made so that it is rarely necessary for the 
physician to be especially equipped. Ficker has devised a 



ACUTE INFECTIOUS DISEASES. 713 

substitute for the Widal method in the form of a glycerine 
emulsion of typhoid bacilli. This has been placed on the 
market as Ficker's Diagnosticum and should prove of great 
practical value to the practitioner. Widal's test consists of the 
introduction of a few drops of blood from a patient suffering 
with typhoid fever into a pure culture of typhoid bacilli. A 
microscopical examination reveals a prompt formation of 
clumps consisting of the agglutinated bacilli, which have also 
lost their motility. The reaction is one of infection and of 
immunity, indicating that a toxic substance has been formed 
in the blood serum, which is capable of destroying the motil- 
ity of the germs causing the disease, and also inducing their 
agglutination. Johnson (Amer. Public Health Assoc, 1896) 
advocated the use of dried-blood specimens as more expedient, 
and this method is now largely employed. By simply redis- 
solving the dried blood, which has been collected upon a 
piece of unglazed paper, with a little water and adding this 
solution ( 1 to 40 or 50 dilution) to an equal quantity of a young 
bouillon culture of typhoid fever bacilli, the reaction is ob- 
tained just as satisfactorily as with the fresh blood. The 
reaction may be observed on the fourth day of the disease, 
but it is usually delayed to the end of the first week. It con- 
tinues throughout the fever and may persist for some time 
after the recovery. The frequently-recorded negative results 
should not weigh heavily against this most valuable diag- 
nostic adjuvant, as faulty technique is probably more to be 
blamed than the test itself. The proportion of cases in which 
a definite reaction occurs and the time of its appearance, 
based on an extended Health Department Laboratory ex- 
perience, is given by Park (Bacteriology), as follows: 20 per 
cent, gave positive results the first week, 60 per cent, in the 
second week, 80 per cent, in the third week, 90 per cent, in 
the fourth week. In 88 per cent, of the cases in which 
repeated examinations were made (hospital cases) the reaction 
was found at some time during the fever. Withington 
{Boston Med. and Surg. Jour., May, 1901) reports two 
46 



714 DISEASES OF CHILDREN. 

hundred and fifty-three cases, with but 4 per cent, failures. 
Its late appearance, usually not before the eighth day, renders 
it less valuable as an early sign. 

The diazo-reaction is a valuable corroborative test, but it is 
also obtained in acute miliary tuberculosis and in rapidly 
progressing pulmonary tuberculosis. In fact, a large num- 
ber of infectious conditions will give this reaction, notably 
measles. I also obtained it in a case of suppurative adenitis. 
For this reason it is not so conclusive as was first supposed. 
It is said to be absent in diphtheria. The reaction is a rose-red 
color imparted to the urine by the addition of ammonia after 
the urine has been treated with Sulphanilic acid and 
Sodium nitrite. It is present from the middle of the first 
week until the end of the fever period ; the presence of 
nephritis interferes with this action. I have been impressed 
with the large number of cases one encounters in which 
the clinical picture presents nothing more than a con- 
tinued fever of remitting type, anorexia, a heavily-coated- 
tongue and constipation. Gurgling in the ileo-csecal region 
and tenderness are usually so ill-defined that they are easily 
overlooked. Rose spots and enlarged spleen may be absent. 
And yet, no other diagnosis than typhoid infection is to be 
thought of, which is eventually corroborated by the Widal 
reaction in the majority of these cases. 

Another aid in the diagnosis of typhoid fever in children is 
the presence of an epidemic. Cases occurring sporadically 
may present difficulties. In all cases of simple continued 
fever occurring during an epidemic the Widal test should 
be made. Sahli, of Bern, during an epidemic, obtained it in 
a number of cases that were sick for only a few days. 

Cases without intestinal localization will present difficulties 
in diagnosis. In such, only a bacteriological examination of 
the blood will solve the problem. Many of the acute typhoid 
septicaemias are of this character. They present the picture of 
a profound toxaemia with high fever and early delirium. Death 
may occur before it is possible to reach a diagnosis, and the post- 



ACUTE INFECTIOUS DISEASES. 715 

mortem findings may be entirely negative (OslER, New York 
Med. Jour., Nov., 1899). In such cases I think we are justi- 
fied in diagnosing typhoid fever, if we are unable to demon- 
strate a lobar pneumonia, or if meningitis can be excluded. 

From malarial fever it is to be differentiated by means of a 
blood examination to ascertain the presence or absence of the 
malarial parasite, and by the temperature curve. 

Meningitis. — A strong point of difference between men- 
ingitis and typhoid fever is the behavior of the pulse. In 
typhoid fever it is relatively slow in the beginning, becoming 
rapid toward the end of the disease ; in meningitis the pulse 
rises proportionately with the fever in the beginning, but be- 
comes slow and irregular towards the close of the case. Fur- 
thermore, in meningitis the abdomen is retracted, the bowels 
are constipated throughout, and paralyses of the cranial nerves 
are to be observed. The reflexes are exaggerated, and 
Kernig's sign may be elicited. None of these symptoms are 
present in typhoid fever. Meningeal irritation is common, 
but true meningitis is very uncommon. In typhoid fever of 
the cerebro-spinal type, it may be necessary to resort to lum- 
bar puncture before a positive diagnosis can be made. 

Acute miliary tuberculosis may present difficulties in 
differential diagnosis. Aside from the absence of the 
Widal reaction in tuberculosis there is a more rapid 
pulse and greater irregularity in the course of the fever. 
Often the " inverted type " of fever is noted. Aside from this 
there is rapid breathing and dyspnoea when the lungs are in- 
volved, together with pronounced catarrh of the- finer tubes. 
An old tuberculous lesion may be demonstrable. True 
meningitis is commonly associated. The most difficult cases 
to differentiate are those in which abdominal symptoms arc 
the predominating feature. 

Early pronounced localization of theinfection in souk- other 
system than the intestinal tract may lead to confusion. As 
Osier (he. cil.) emphasizes, the brunt of a very acute infec- 
tion may fall upon the cerebro-spinal, the pulmonary, or the 



716 DISEASES OF CHILDREN. 

renal system. Such eases would be more appropriately 
designated " typhoid infection " than " typhoid fever." 

Treatment. — The patient shpuld be put to bed at once in a 
room that can be freely ventilated, and from which all un- 
necessary furniture and draperies have been removed, not es- 
pecially on account of any degree of contagiousness on the 
part of the fever, but in order to give as much air-space as 
possible and make it less difficult to keep the room clean. 

Provision must be made for the disinfection of the stools 
and urine, which can be accomplished by the use of an active 
germicide. A strong solution of chloride of lime, Piatt's 
chlorides, or carbolic acid (5 per cent, solution) is to be poured 
over the stools as soon as they are passed, and allowed to act 
upon them for several hours before they are emptied into the 
water-closet. All towels, napkins and sheets soiled by the 
patient should be boiled in order to render them sterile. 

The diet is of the greatest importance. Owing to the in- 
testinal lesions, solid food must be withheld until at least a 
week after disappearance of the fever, diarrhota and abdo- 
minal tenderness. Where abdominal symptoms have been 
pronounced during the fever, it is better to wait even longer 
before resuming solid food. In the milder class of cases we 
may return to semi-solid food on the fifth day after the temper- 
ature has ceased to rise above ioo° F., gradually returning to 
solid food. Such articles of diet as thoroughly cooked cereals • 
poached eggs ; milk toast ; the soft portion of a baked apple ; 
baked potato, etc., should be selected at this time. 

Although milk is looked upon as an ideal liquid food, still 
it does not act as such in many cases, and, when given un- 
modified, may pass through the bowels in firm curds. The 
stool should, therefore, alw T ays be inspected when administer- 
ing milk, as such curds may induce most unfavorable symp- 
toms. A notable ill-effect of milk observed in some patients is 
tympanitis; this promptly disappears when the milk is dis- 
continued. In young children it is always best to dilute the 
milk with barley-water, or administer it predigested. 



ACUTE INFECTIOUS DISEASES. 717 

Strained vegetable soup, made with mutton and a variety of 
fresh vegetables, is a most valuable food, and an agreeable 
change to the patient. Likewise grape juice, when diarrhoea 
is not prominent ; and any of the reliable proprietary foods 
such as Horlick's Malted Milk, Eskay's food, and Mellm's 
food (the latter when there is constipation), are all of value. 
The mistake, however, is to feed the patient without any de- 
gree of regularity or restriction as to quantity, changing 
from one article to another promiscuously. The best results 
are obtained by selecting the food best adapted to the case, 
and administering three to four ounces every three hours. 
Some variation in the character of the diet is most agreeable 
to the patient and a great aid in keeping up the nutrition. 
The carbohydrates are especially valuable in preventing the 
marked emaciation so prone to occur in typhoid fever. The 
patient should also receive water f reel v. 

The child must be sponged daily with cold or tepid water 
and alcohol (one part to four of water), and when the fever 
runs high, remaining above 103 degrees F. during the greater 
period of the twenty-four-hour range, these baths may be re- 
peated every three hours. Should this fail to control the 
fever, a cold cheese-cloth pack may be tried, or, what I prefer, 
sprinkling the body with water at 70 to 80 degrees F., and at 
the same time applying friction to the extremities. In order 
to carry out this procedure, the child is stripped and laid on 
an oil cloth sheet over which a linen sheet is spread, while the 
head of the bed is elevated so that the water may run off into 
a bucket. The water may be poured from a watering-can cr 
it may be freely squeezed from a large sponge. Sometimes 
rubbing the body briskly with pieces of ice wrapped in a 
towel will have a most grateful and beneficial action in cases 
of hyperpyrexia. I have found these methods a good substi- 
tute for the full bath (see p. 18). Should the patient read 
poorly after any form of cold water treatment it is better to 
desist and use milder measures (luke-wann Sponging). 

The Indications for the Differt nt Hydrotherapeutic Measures 



718 DISEASES OF CHILDREN. 

in Typhoid Fever. — It is a mistake to attempt to treat all 
cases of typhoid fever on the same plan, and by "hydro- 
therapy" to understand simply the cold bath treatment. 
While the majority of cases are eminently suited to this mode 
of treatment in one of its forms, i. e., the full bath, the cold 
sponge bath, or the cold shower bath, still there are those 
in which the baths fail either to improve the case or actually 
aggravate the condition. In such the ice-bag may do good, 
or intestinal irrigation with luke-warm water (enteroclysis) 
may be the therapeutic measure indicated. The explanation 
for this apparent disparity is as follows : Where the brunt of 
the infection falls upon the vasomotor centres and the pulse 
is weak, rapid and dicrotic and the peripheral circulation 
poor (vasomotor -paresis), the intermitting cutaneous shock 
produced by the cold bath is the form of treatment indicated ; 
where the localization is primarily intestinal and there is in- 
tense inflammatory reaction and tendency to haemorrhage and 
perforation the ice-bag is useful while the bath may do harm, 
and where toxaemia predominates and the cerebro-spinal ner- 
vous system and the kidneys are chiefly attacked, enterocly- 
sis, by favoring elimination and lowering temperature, is the 
form of treatment that will do the most good. Some patients 
present such a pronounced idiosyncrasy against cold water or 
are in such a condition in which reaction is impossible, 
that it becomes positively harmful to persist in giving them 
cold baths or cold sponging. Here luke-warm water, espe- 
cially if it be allowed to evaporate from the body and in that 
manner abstract heat, is beneficial and should be resorted to* 
In hyperpyrexia in children who do not stand cold water, 
sponging with hot water, especially along the spine, has often 
proved beneficial. 

Stimulation may become necessary in the later stages of 
the fever. The first and most prominent indication is car- 
diac weakness. Daily auscultation of the heart should be 
practiced and when the first sound loses its muscular ele- 
ment and resembles the second sound (embryocardia) alco- 



ACUTE INFECTIOUS DISEASES. 719 

holic stimulation should be resorted to. Other indications 
are continuous delirkim of the low muttering variety ; dry, 
trembling tongue ; tympanitis and pronounced adynamia, 
and I may add lack of reaction to remedies. Many of our 
remedies act prominently in a stimulating way, but we meet 
cases in which the system fails to respond to them until re- 
action has been brought about by physiological means. A 
teaspoonful of whiskey diluted with water may be given 
every two to three hours to be decreased or increased accord- 
ing to circumstances. Collapse will call for strychnia. 

Haemorrhage, if slight, requires nothing more than tem- 
porary withdrawal of food followed by greater caution in 
feeding, absolute quiet of the patient and possibly a change 
of remedy. When severe, it proves a grave complication. 
A cold application to the abdomen in the form of Leiter's 
tubes or an ice bag will prove of great benefit. Absolute 
rest must be enjoined, even the bed pan may be put 
aside and clothes used to collect the excreta. If collapse 
threatens, stimulants must be used. They should, however, 
be used cautiously, as overstimulation of the heart may favor 
increased haemorrhage. Strychnia nitrate, hypodermically, is 
perhaps the best stimulant to employ. Geranium tincture, 
per rectum, as recommended by Dr. Woodward {Eclectic Med. 
Jonr., June, 1901) using two ounces of tincture in a pint of 
milk and water, seems a most valuable adjuvant. Infusion of 
a normal saline solution where loss of blood was great has 
saved life. 

Perforation and peritonitis are extremely fatal com plica, 
tions, although early laparotomy in perforation before peri- 
tonitis has set in offers better hope for the patient than con- 
servatism according to the observations of Finney and Keen. 

Wescott collected eighty-three well authenticated cases of 
perforation that were operated, of which number sixteen re- 
covered, making a mortality of 80.6 per cent. Comparing 
this with Murchison's figures of 90 per cent, to 95 per cent, 
mortality among unoperated cases, operative interference 



720 DISEASES OF CHILDREN. 

seems to offer much for the future. Five of these cases were 
in children under fifteen years, of which two recovered. The 
most favorable time to operate has been the second twelve 
hours after perforation, but under certain circumstances it 
may be more prudent to operate earlier. Operation should, 
however, always be deferred until the primary shock has 
worn off. (KEEN, Surgical Complications and Sequels of 
Typhoid Fever.) 

The leading typhoid fever remedies are Baptisia, Bryonia, 
Gelsemium and Rhus tox., and in certain epidemics one of 
these remedies may be indicated in almost every case. The 
selected remedy should be continued throughout the entire 
course of the disease unless positive indications for a change 
of remedy present themselves ; even in such an event it is 
wise to return to the first remedy when the intercurrent has 
corrected the symptoms for which it was chosen. Thus, in 
many epidemics Bryonia will be found the chief remedy, and 
although indications for Hyoscyamus, Phosphoric acid, or 
some other remedy of a similar sphere of action may arise 
during the progress of the case, a return to Bryonia may, as a 
rule, be made with advantage as soon as these symptoms have 
been controlled. 

It is not at all rare to find cases running a short and uncom- 
plicated course receiving but a single remedy during the entire 
period, providing the remedy has been carefully selected 
from the beginning. In a disease like typhoid fever, which 
we may expect to assume a most grave aspect at any moment, 
we must prescribe with caution and precision from the begin- 
ning and only change the remedy after mature deliberation. 
As to repetition of the dose, it has been my experience, 
in common with that of many others, that the best results 
are obtained from a frequent administration of the remedy 
when symptoms are urgent, lengthening the intervals as soon 
as. improvement is noted. 

The following indications embrace the most important 
symptoms of the leading remedies at our command : 






ACUTE INFECTIOUS DISEASES. 721 

Agaricus. — In typhoid fever where the nervous symptoms 
predominate. Low fever, tremulous tongue, and general 
tremor of the entire body. Among adults it is recommended 
for drunkards in whom the heart is giving out. Alcoholic 
stimulants must, of course, not be withheld from such cases. 
We often encounter boys who smoke cigarettes excessively 
and whose nervous system is about as wretched as the adult 
drunkard's. Here Agaricus is well indicated. 

Apis. — Remitting type of fever. Chilliness in afternoon 
with oppression of breathing; heat without thirst; later, un- 
consciousness with involuntary stools ; dry tongue, which is 
cracked and covered with aphthae, difficult to protrude; diffi- 
cult deglutition ; scanty urine ; muttering delirium. 

Arnica. — General stupefaction of the senses ; general sore- 
ness, bed feels too hard ; the sleep is disturbed by anxious 
dreams ; the tongue is red and dry, with a brown streak down 
the centre ; putrid taste in mouth ; fetor ex ore ; involuntary 
discharge of faeces and urine ; the extremities become cold 
while the head remains hot ; haemorrhages and bedsores de- 
velop. 

Arsenicum. — Low types of typhoid, usually the later stages 
in unfavorable cases. Farrington cautions against the early 
use of Arsenic in typhoid fever, and considers it a remedy 
capable of doing harm unless clearly indicated. It is most 
useful in the young or aged, or in those debilitated by pre- 
vious ailments. The general symptoms are so characteristic 
of Arsenic, such as great restlessness, prostration ; thirst for 
small quantities of water ; hot, dry skin ; general aggrava- 
tion of all symptoms soon after midnight or noon ; cadaverous 
smell of the discharges as well as of the patient, are all 
prominent indications for its use. " Its true place is there, 
where rotten, putrid and cadaverous stools and dry, wooden 
tongue indicates a degree of disintegration of the vital fluids 
which Rhus no longer can check." (Jahk.) 

Baptisia. — The well-known mental symptom, the halluci- 
nation that the body is dismembered, that certain parts of 




722 DISEASES OF CHILDREN. 

the body are double, or that there is a second self in the bed 
with the patient, is a strong indication for Baptisia, although 
its absence by no means deprives this drug of its usefulness 
in typhoid fever. Phosphorus and Petroleum both have simi- 
lar symptoms. The condition calling for Baptisia is charac- 
terized by great weariness and a bruised feeling of all the 
limbs, together with a low type of fever and physical prostra- 
tion ; offensive diarrhoea ; breath, sweat and urine are alike 
offensive ; there is dull, stupefying headache ; the patient is 
delirious, sleeps heavily and is aroused with difficulty. The 
tongue is dry and brown, the conjunctivae are injected; the face 
is flushed and presents a besotted expression ; exhaustion is 
marked. Baptisia may be indicated early in the disease 
when the symptoms are intense from the beginning, thus ex- 
cluding such remedies as Bryonia and Gelsemium. 

Bryonia. — Bryonia may be indicated at any stage, although 
its most frequent application will occur during the first stage. 
The symptoms calling for its selection are very characteristic 
and prominent — irritability, lassitude, desire to remain quiet 
and sleep ; headache, worse from opening the eyes or moving 
the head ; dryness of the lips, mouth and throat, with thirst 
for large quantities of water ; aching of the limbs, worse from 
motion ; frequent brown, putrid stools ; delirium at night 
and restless sleep, disturbed by dreams of daily affairs ; wants 
to go home ; visions when closing the eyes. 

Carbo veg. — Carbo vegetabilis is indicated in extreme 
cases. It has well been said: "The Carbo vegetabilis patient 
is dying," nevertheless, reaction may take place even in such 
a serious state as it pictures. Many writers speak very highly 
of this remedy, but personally I am not able to say what 
Carbo vegetabilis will do, as in such a condition I never fail 
to resort to stimulation. The picture is a familiar one — pro- 
gressive stupor ; lustreless eyes ; with sluggish pupils ; Hip- 
pocratic countenance ; parched tongue ; distended abdomen ; 
involuntary diarrhoea ; haemorrhages from the nose, mouth 
or intestinal tract ; cold extremities, the coldness gradually 



ACUTE INFECTIOUS DISEASES. 723 

extending from the feet up to the knees; small, frequent 
pulse, at times imperceptible ; decubitus. The Carbo vege- 
tabilis patient is passive, the Arsenicum patient restless. 

Gelsemium. — In the early stages Gelsemium is frequently 
indicated on the symptoms of lassitude, drowsiness, dull 
headache, with heaviness of the eyelids and photophobia ; 
slow, intermitting pulse, accelerated from slight exertion ; 
blueness of the lips ; chilliness up and down the spine ; epis- 
taxis ; catarrhal condition of the eyes and respiratory tract ; 
diarrhoea. 

Hamamelis. — Haemorrhages of dark, fluid blood from the 
bowels, with great soreness of the abdomen. 

Hyoscyamus. — The delirium indicating Hyoscyamus is 
characterized by loquacity, obscene actions, or even attempts 
at violence. The patient picks at the bed-clothes and grasps 
at flocks in the air, with continual muttering. Stramoniu))t 
is similar, but the loquacity is confined to one subject and 
the patient is more noisy, often crying out in terror from sup- 
posed visions of horrible animals, bugs, and the like, which 
he sees coming out of the floor, crawling along the ceiling, 
etc. The automatic movements of the extremities occurring 
during the delirium are also characteristic in both drugs, but 
in Hyoscyamus they are more jerky and spasmodic. Hyoscya- 
mus also has total loss of consciousness, with dry tongue, 
involuntary stools, subsultus tendinum, dribbling of urine. 

Lachesis. — The Lachesis patient, similar to the condition 
noted under Hyoscyamus, is also loquacious, but he jumps 
from one subject to another in an incoherent manner ; 
there is stupor, dropping of the lower jaw; dry, red, or blackish 
tongue which is red at the tip and bleeding, and trembles on 
being protruded; the stools are horribly offensive, the abdomen 
sensitive to touch, and all symptoms are more intense after 
sleep. 

Mercurius. — The characteristic nocturnal aggravation, the 
greenish-yellow stools, broad, flabby tongue and drowsiness 
may indicate Mercurius, especially when there is hepatic dis- 
turbance in connection with the case. 



724 DISEASES OF CHILDREN. 

Muriatic acid. — Low types of typhoid fever, in which the 
patient is stupid, sliding down to the foot of the bed; the 
tongue is parched and dry, difficult to protrude ; stools invol- 
untary while passing urine ; loud moaning during sleep, and 
when awake not fully conscious of his surroundings. 

Opium. — Hither complete loss of consciousness with loud, 
stertorous breathing, contracted pupils, face dark red and 
bloated or pale with death-like expression, dropping of the 
lower jaw, hot sweat, or delirium with sleeplessness due to 
hypersesthesia of the special senses, so that slight noises keep 
him awake. 

Phosphoric acid. — Low typhoid state, in which the patient 
becomes totally indifferent to his surroundings. He can be 
aroused, but with difficulty, and soon relapses into his apa- 
thetic condition. There is great debility, rattling of mucus in 
the chest, rumbling in the abdomen, tympanitis, grayish 
watery stools, bleeding from the nose, red streak through the 
centre of the tongue, milky urine, clammy skin. 

Rhus tox. — After Bryonia and Gelsemium, Rhus toxicode?i- 
dron and Daptisia frequently follow. The provings of Rhus 
tox. present a typical typhoid state, and the anatomical 
changes in the intestines closely correspond to the lesions of 
typhoid fever. The symptoms are sharp and well-defined, as 
is the case with Bryonia. The mind becomes beclouded and 
the mental operations are performed with difficulty. The 
patient is restless from a distressing aching in every limb, 
and constantly changes his position to gain relief (not as in 
Arnica, where there is soreness produced by lying in one par- 
ticular attitude, which makes him seek a new position). The 
sleep is restless, disturbed by dreams of great physical exer- 
tion. The lips are brown and dry, and the teeth are covered 
with sordes ; the tongue is likewise brown and dry, present- 
ing a triangular red tip. The diarrhoea is worse during the 
night, often involuntary during sleep. Beside this, there may 
be bronchitis, hypostatic pneumonia with bloody expectora- 
tion, and bleeding from the nose. Active irritative symptoms 



ACUTE INFECTIOUS DISEASES. 725 

referable to the cerebrospinal system indicating profound ty- 
phoid toxaemia often yield better to Rhus to.v. than to such 
remedies as Hyoscyamus, Helleborus and Stramonium. It is 
not always possible to get clear-cut indications upon which 
to differentiate these drugs, and under such circumstances 
Rlius should be given the preference if it is a clear case of 
typhoid fever in the second or third week. 

Stramonium. — The Stramonium stool is blackish and hor- 
ribly offensive; the noisy delirium, has been alluded to 
under Hyoscyamus. Suppression of urine during typhoid 
fever is a prominent symptom. 

Sulphuric acid. — Protracted cases, especially in children 
with aphthous stomatitis ; stools like chopped eggs and very 
foetid; haemorrhages, with rapid sinking of the vital forces; 
desire for stimulants. (AiXEN.) Similar to Phosphoric acid, 
but more intense. 

Veratrum viride. — Veratrum viride is indicated when 
there is furious delirium ; full, tense pulse, later becoming 
soft and irregular ; red streak down the centre of the tongue ; 
pneumonic complications. Tartar emetic ma}- likewise be 
called for in dyspnoea, cyanosis, rattling of mucus in the 
bronchial tubes, subcrepitant rales, and oedema of the lungs. 

DIPHTHERIA. 

Diphtheria is an acute infectious, highly-contagious disease 
due to a specific micro-organism. While diphtheritic inflam- 
mations of mucous membranes may result from other micro- 
organisms — notably from the streptococcus pyogenes — still the 
term "diphtheria" should be restricted to those cases of 
pseudo-membranous pharyngitis and laryngitis due to the 
specific diphtheria germ. The other condition, described as 
pseudo-diphtheria, or diphtheroid, embraces those anginas 
complicating scarlet fever, measles, and occasionally others to 
the infectious diseases, or occurring primarily as "diphtheritic 
sore throat," being due to infection with the streptococcus 
or some other organism (staphylococcus, pneumococcus). 




726 DISEASES OF CHILDREN. 

The appearance of the membrane and the accompanying 
symptoms should differ greatly in these two conditions, so 
that a differential diagnosis might be made upon a clinical 
examination alone ; but it must be remembered that mixed 
infection is quite a common occurrence, and that in such cases 
confusion may arise. Again, true diphtheria may present an 
entirely atypical exudate and the concomitant symptoms be 
of a mild type, while, on the other hand, a streptococcus 
angina may be accompanied by high fever and considerable 
adenopathy. For this reason it is unwise to attempt to make 
a diagnosis of diphtheria upon the appearance of the throat 
and the associated symptoms alone, never neglecting a 
bacteriological examination in any case presenting mem- 
branous exudate upon the tonsils. 

Membranous croup is that form of diphtheria in which 
primary infection takes place in the larynx with the develop- 
ment of a diphtheritic membrane, which may either remain 
confined to the larynx or spread upward or downward, involv- 
ing the pharynx and trachea secondarily. 

Faucial diphtheria frequently invades the larynx second- 
arily, the resulting laryngeal symptoms being identical with 
those of a fully-developed case of croup ; but the clinical 
picture presented by a case of primary croup differs so mark- 
edly from the manifestations of faucial diphtheria that its 
description, like that of pseudo-diphtheria, must be con- 
sidered separately. 

The Klebs-Loeffler bacillus is a micro-organism varying 
greatly in size, being broad, straight or slightly curved, and 
presenting a club-like extremity. It contains highly refrac- 
tile, oval bodies, which take the stain more deeply than the 
bacillus itself, the best stain for bringing out these bodies be- 
ing an acidulated solution of methylene blue, a counter-stain 
of aqueous Bismark brown being used to stain the body of 
the bacillus. This is known as Neisser's Stain and the best 
results are obtained in young cultures (from 6 to 12 hrs.). As 
the bacillus will grow readily upon Loefner's blood-serum 



ACUTE INFECTIOUS DISEASES. 727 

at a temperature of 8o° F. to ioo° F., it is a simple matter 
to carry out this most important procedure, even in private 
practice. The examination of smears from the throat is neither 
accurate nor satisfactory. A bacillus may be found, irregular 
in shape and taking the stain (Loeffler's methylene blue) irreg- 
ularly, but in order to be absolutely certain we must make a 
culture and observe its mods of growth (delicate grayish 
colonies) and study the early-appearing growth for the above 
mentioned peculiarities. 

The bacillus is spread by the discharges from the mouth, 
throat and nose, and may persist for a long time in the throat 
of a patient after recovery. Infection may take place either 
directly from the patient, or indirectly through the medium 
of articles of bedding, clothing, toys. etc. It may also be 
spread through the agency of a third person. We should, 
however, remember that a child with a perfectly healthy 
throat is less liable to contract the disease than one with a 
catarrhal angina, slight superficial erosions of the mucous 
membrane, enlarged tonsils, naso-pharyngeal catarrh and 
catarrhal laryngitis. 

Pathology. — Pathologically, a diphtheritic inflammation 
presents a pseudo-membrane, which is inseparably attached 
to the deeper layers of the mucous membrane upon which 
it develops, the entire mucosa having undergone a process 
of coagulation necrosis, accompanied by the exudation of 
fibrin. Such a condition is rarely met with, however, in 
Klebs-Loefner diphtheria of the fauces and larynx, a croupous 
exudation of varying thickness, separating without leaving a 
lacerated surface, being the pathological process usually en- 
countered. The true diphtheritic process, resulting in ulcera- 
tion and sloughing, is more likely to take place in scarlatinal 
pseudo-diphtheria (septic angina), or in eases of septic diph- 
theria where mixed infection exists. 

The membrane consists of a dense network of fibrin, con- 
taining in its meshes pus-cells, dead epithelial cells and 
numerous micro-organisms. The Klebs-Loeffler bacillus can 






728 DISEASES OF CHILDREN. 

be demonstrated in the upper and outer layers of the mem- 
brane. The mucous membrane underlying and adjacent to 
the pseudo-membrane is found in inflammatory reaction, 
though rarely oedematously swollen unless pyogenic micro- 
organisms are plentifully admixed with the bacillus. 

The lymphatic glands of the neck are markedly swollen, 
but do not tend to break down*. The surrounding structure 
may present a puffy appearance. The glandular enlargement 
is most marked in cases complicated by invasion of the pos- 
terior nares. When the process is confined to the larynx they 
may not be involved at all. 

Parenchymatous degeneration of the heart, kidneys and 
liver are the changes observed in the internal organs. A 
secondary broncho-pneumonia (inhalation pneumonia) is rarely 
absent in severe and fatal cases. Here the Klebs-Loefner 
bacillus is usually found in the lungs. In sixty-two cases 
of broncho-pneumonia, associated with diphtheria, reported 
by Pearce, {Jour. Bost. Soc. Med. Sciences, June, 1897) 
the bacillus was present in fifty-two instances, being the only 
organism present in seventeen cases. The streptococcus pyo- 
genes was also prominently present. The changes occurring 
in the nervous system, which become manifest at a somewhat 
later period than those observed in the other tissues, are 
parenchymatous degeneration of the myelin sheath of the 
nerves, affecting both motor and sensory fibres alike (Bat- 
ten, British Med. Jour., Nov., 1898), and at times degen- 
erative changes in the gray matter of the cord, cerebellum and 
brain. 

Symptomatology. — A typical case of pure diphtheritic infec- 
tion presents the following characteristics : The child will 
usually complain of sore throat for a day or two, which may 
not attract special attention until fever, offensive breath, 
prostration and swelling of the glands at the angle of the jaw 
become apparent. An examination of the throat at this stage 
of the disease reveals a deposit of false membrane, usually 
upon one of the tonsils, associated with slight swelling of the 



ACUTE INFECTIOUS DISEASES. 729 

same and redness of the mucous membrane. This may, how- 
ever, be slight, in consideration of the serious nature of the 
condition, and in fact the mucous membrane in some instances 
will appear pale rather than congested. Likewise the pain 
on swallowing may be so inconsiderable as to attract little or 
no attention. I have had children brought to my clinic in 
whom both tonsils were covered with membrane, and yet these 
children had not complained of their throats sufficiently to 
lead the parents to suspect the true nature of the case. 

The membrane is of a grayish or yellowish-gray color, and 
firmly adherent to the subjacent mucous membrane ; in fact, 
it requires more or less force to remove it, which usually re- 
sults in some traumatism to the mucosa. This is a patho- 
gnomonic sign of diphtheria, and taken in conjunction 
with the swollen lymphatics, the offensive breath and the 
moderate degree of fever, a diagnosis of true diphtheria 
can usually be made without hesitation, which a bacterio- 
logical examination will subsequently verify. Instead of 
beginning as a single patch, there may be seen isolated 
dead-white spots of varying size upon one of the tonsils, 
which may remain discrete throughout the entire course, 
if the disease does not assume a severe type. Usually, 
however, they unite into one large, irregular patch, and the 
opposite tonsil, from being brought into contact with the 
affected one during deglutition, soon develops a similar mem- 
brane. 

In severe cases the membrane spreads rapidly from its peri- 
phery, travelling along the margin of the soft palate, cover- 
ing the uvula, which becomes elongated and swollen, and 
finally invading the opposite half arch and coalescing with the 
membranous deposit of the other tonsil. It also spreads pos- 
teriorly to the pharynx, whence it may invade the posterior 
nares or the larynx. When membrane develops at this rapid 
rate it sometimes appears simply to run over the mucosa as a 
delicate fibrinous exudate, the epithelium beneath it remain- 
ing intact for some time. 
47 






730 DISEASES OF CHILDREN. 

In a steadily progressing case the above distribution of the 
membrane will have been completed in about three to four 
days from the time of onset. At this time the membrane can 
be studied in various stages of development. At the site of 
origin it will be found to have attained considerable thick- 
ness, being of a brownish or dirty grayish color, with a well- 
defined outline and areola, and a thick, partly detached border, 
while in another direction it fades ont into a thin, grayish 
film, which is invading new territory. This film likewise 
thickens and assumes the same color as the other portion of 
the membrane, which now shows a tendency to become loose. 

By the fifth or sixth day the process has reached its acme, 
and in the course of three or four days the membrane sepa- 
rates spontaneously, providing the patient has not succumbed 
to the disease or has not had antitoxin. (In the cases receiv- 
ing antitoxin early, the conrse is materially shortened.) A red 
areola of reactionary inflammation is seen about its border, 
and it gradually loosens and comes away in pieces, leaving 
behind a reddened, slightly swollen and readily bleeding mu- 
cous membrane. Coincident with these changes the consti- 
tutional symptoms rapidly improve, and the patient is on the 
road to convalescence. 

The symptoms accompanying the diphtheritic process are 
those of a most grave toxaemia. As pronounced symptoms may 
be delayed until the disease is far advanced, they are seldom of 
diagnostic valne. The child complains of lassitude, anorexia 
and sore throat ; repeated chilly sensations and headache may 
also be present. Fever is usually not high in the beginning, and 
may remain at a comparatively low point throughout the entire 
course, fluctuating between icu° to 103 F. An abrupt onset, 
however, with high fever, headache, severe pain in the throat and 
considerable swelling of the tonsils, may take place. In such 
cases the early symptoms may be due to an admixture of the 
streptococcus. This, however, is not necessarily the case, for 
diphtheria is most irregular in its clinical manifestations. 
There are cases in which even in the presence of considerable 



ACUTE INFECTIOUS DISEASES. 731 

membrane constitutional symptoms are entirely wanting. 
Again, the most serious symptoms, even sloughing of the soft 
tissues and suppuration of the lymphatic glands may result 
from the diphtheria bacillus alone without the intervention 
of a secondary infection. 

The lymphatic glands at the angle of the jaw are involved 
early in a typical case, but the adenopathy may be so slight, 
as to escape notice. Absence of adenopathy is by no means 
evidence against the presence of diphtheria. 

The pulse becomes rapid and weak during the later stages, 
the heart being affected to a marked degree by the toxins of 
diphtheria. Sudden death may take place from cardiac pa- 
ralysis during the height of the disease, or it may not occur 
until the child is convalescing, following upon some incau- 
tious physical exertion. The myocardium, as well as the in- 
nervation of the heart, is affected by the toxin. In some 
cases the pulse becomes slow and irregular ; this is prob- 
ably a sign of myocarditis. 

The tongue is coated from the beginning and the breath 
characteristically offensive. The bowels are generally con- 
stipated. Albuminuria is found in many cases ; it usually 
clears up promptly, simply indicating acute degeneration of 
the kidneys as a result of the elimination of toxins. 

Diphtheritic paralysis occurs more frequently in adults than 
in young children, being seen seldom under two years. The 
severity of the case does not necessarily indicate the amount 
of paralysis which is to be expected, for cases with but a small 
amount of membrane may be followed by considerable paraly- 
sis, and vice versa. The clinical picture is that of a multiple 
neuritis, the pathological changes in the nerves having been 
described above. Symptoms may occur while the membrane 
is still present, but this is unusual. In the majority of cases 
they do not occur until two or three weeks after recovery. 
Paralysis of the soft palate is the first symptom noticed, man- 
ifesting itself by nasal voice, regurgitation of food through 
the nares, and difficulty in swallowing. 



732 DISEASES OF CHILDREN. 

The eye-muscles are frequently affected early, and loss of 
accommodation, strabismus and ptosis are the disturbances 
encountered here. When the extremities take part in the 
paralysis the patient will complain of muscular weakness, 
with tingling and numbness, gradually increasing in severity 
until he is perhaps unable to walk or use his arms, although 
complete paralysis is rare. When the extremities become in- 
volved the paralysis is symmetrical. Sensation is markedly 
impaired and the knee-jerk lost, even at times without the 
existence of paralysis. The prognosis as to ultimate recovery 
is good, although the course is variable, some cases continu- 
ing for several months before improvement sets in. Death 
may result from paralysis of the respiratory muscles. 

Extension of the membrane to the nose is indicated by nasal 
obstruction with an acrid, offensive, muco-purulent discharge 
and increased swelling of the lymphatic glands at the angle 
of the jaw, together with involvement of the submaxillary 
glands. Epistaxis occurring during diphtheria is always a 
suspicious symptom. Owing to the large absorbing surface 
brought in contact with the toxins, constitutional symptoms 
are markedly aggravated, and prostration becomes extreme. 
Primary nasal diphtheria is, as a rule, not nearly as grave a 
condition as the secondary form, although such a case may 
infect another child with a faucial diphtheria of the usual 
severity. (For a full discussion of nasal diphtheria see 
Pseudo-membranous Rhinitis, pages 549 and 550.) 

Extension into the larynx is indicated by progressively in- 
creasing dyspnoea, cyanosis, and a croupy cough. The pro- 
cess may result in complete stenosis of the larynx, with death 
from suffocation. 

Septic diphtheria is characterized by the addition of sepsis 
to the diphtheritic condition. It was formerly supposed that 
this form of diphtheria is invariably due to mixed infection 
with the streptococcus, but it is now known that even the 
most virulent cases with all the outward signs of a septic in- 
fection may be due to the Klebs-Loefner bacillus alone. The 



ACUTE INFECTIOUS DISEASES. < 33 

throat assumes a dirty grayish color, or even blackish where 
blood extravasation into the false membrane has taken place, 
and a cadaverous stench emanates from the mouth. A tena- 
cious brownish mucus covers the tongue and lips, and an 
acrid discharge runs from the nostrils. The lips are dry, 
swollen and cracked, and ma}- be covered with patches of 
false membrane. Swelling of the lymphatics at the angle of 
the jaw is pronounced, and is accompanied by infiltration of 
the cellular tissue of the neck. The pulse is rapid and feeble, 
the extremities become cold, and prostration is profound. The 
temperature fluctuates greatly, and in a given case may range 
from subnormal to a hyperpyrexia. Septic cases are usually 
rapidly fatal, succumbing to the toxaemia more often than to 
laryngeal involvement. 

Laryngeal Diphtheria or Membranous Croup is a primary 
infection of the larynx characterized by the formation of a 
false membrane (croupous exudate) upon the laryngeal mu- 
cous membrane. The false membrane may remain confined 
to the larynx, or extend down into the trachea and up into 
the pharynx. Often it is accompanied by a scanty tonsillar 
exudation. Laryngeal diphtheria presents few of the char- 
acteristic symptoms of faucial diphtheria for a number of rea- 
sons. In the first place, the bacillus causing croup is usually 
less virulent than that found in faucial diphtheria. Again, 
owing to the feeble absorptive power of the mucous mem- 
brane lining the larynx, glandular enlargement does not take 
place, and as constitutional symptoms are delayed for the 
same reason, they are not frequently observed, owing either 
to the rapidly fatal course of the disease or to a checking of 
the process before symptoms have had time to develop. 
Goodno states that the fatal cases of primary pseudo-mem- 
branous laryngitis observed by him which were subjected to 
tracheotomy, and lived long enough to develop constitutional 
symptoms, died as diphtheria patients die. 

The onset is insidious, witli moderate fever, eronpv cough, 
and hoarseness. During the first few days symptoms are 



734 DISEASES OF CHILDREN. 

slight and only point to a catarrhal laryngitis, nocturnal ag- 
gravations frequently occurring from spasm of the vocal 
cords. When, however, an exudate is seen upon the tonsils, 
or down in the pharynx, we are justified in suspecting the 
diphtheritic nature of the case. At the end of from three to 
four days laryngeal obstruction has become the chief feature 
in the case. The voice is hoarse or entirely lost ; during in- 
spiration a harsh, tubular sound (stridulous respiration) is 
heard, and the act is accompanied by retraction of the supra- 
clavicular and intercostal spaces and the lower border of the 
thorax. Recession of the epigastric region during inspiration 
is a sign by which we can most satisfactorily guage the de- 
gree of laryngeal obstruction in young children. The child 
usually sits erect, and every effort at inspiration is laboriously 
performed, all of the accessory respiratory muscles being 
thrown into action. With progressing stenosis the body sur- 
face becomes cold and cyanotic, and the child becomes drowsy 
and later comatose, dying from asphyxia. Death may result 
in a few days from the time of onset, although the course is 
usually somewhat longer. With the intervention of surgical 
measures (intubation and tracheotomy) the case presents a 
less unfavorable prognosis. 

Pseudo-Diphtheria, or Diphtheroid, differs from true bacil- 
lary diphtheria both etiologically and symptomatically. Such 
a diphtheritic process may develop independently or compli- 
cate scarlatina, measles, etc. As a complication of scarlatina 
it appears, however, more frequently and more virulently than 
in any other form. In this disease an angina of almost any 
grade of severity seems possible, the virus of scarlatina exert- 
ing direct and specific influence upon the throat, and permit- 
ting of the development of the gravest forms of diphtheritic 
inflammations. 

The streptococcus pyogenes is the germ most frequently 
found in pseudo-diphtheria, as was first demonstrated by 
Prudden. Although other micrococci, notably the staphy- 
lococcus aureus and albus y are sometimes found alone in these 



ACUTE INFECTIOUS DISEASES. 



735 



cases, or in association with the streptococcus, still they play 
a less important role than the latter, which is capable of pro- 
ducing the most destructive manifestations. The work of 
Filatow {Vorlesungen ii. Infections-Krankheiten im Kind- 
esalter, 1897) fully confirms these observations, and he is led 
to the belief that all '" scarlatinal-diphtherias " are strep- 
tococcus anginas ; furthermore, pseudo-diphtheritic strep- 
tococcus angina may be encountered as an independent 
disease, occurring without scarlet fever. Holt states that 
from 25 to 35 per cent, of cases formerly sent to hospitals 
with a clinical diagnosis of diphtheria were really cases of 
pseudo-diphtheria. 

Vierordt {Berliner Klin. IVochenschr., 1897) found in a 
series of diphtheroid anginas both streptococci and staphy- 
lococci, and in one case a diplococcus. The Klebs-Loeffler 
bacillus was present in none or these cases. The membrane 
did not extend to the nose or pharynx, but in the greater 
number it passed beyond the tonsils in the direction of the 
soft palate. Boulloche (Les Aug ines a Fausses Membranes) 
divides the various pseudo-diphtheritic anginas into the fol- 
lowing classes : streptococcus angina, staphylococcus angina 
and pneumococens angina. He considers them non-contagious 
and usually mild in their course. I have encountered the 
pneumococens in a few of my cases. 

Although these bacteria are found as contaminations in 
most cases of diphtheria, still they do not modify the course 
of the disease unless present in large numbers, aud even then 
it is only the streptococcus which materially alters the nature 
of the case, the bacillus-streptococcus combination being the 
most unfavorable form of infection, producing a septic diph- 
theria. 

The clinical course of pseudo-diphtheria is quite different 
from that of bacillary diphtheria. In cases of mixed infec- 
tion a clinical differentiation becomes difficult or impossible. 
In pseudo-diphtheria there is pronounced inflammation ^i the 
pharynx and tonsils, with redness, swelling and pain. It be- 



736 DISEASES OF CHILDREN. 

gins abruptly, with high fever, lassitude and headache. Soon 
small, white or yellowish patches are seen to develop upon 
the tonsils ; they become darker in color and may coalesce, 
but seldom spread beyond the tonsils. The membrane is 
more friable than that of true diphtheria, and can usually be 
detached without much difficulty. 

Swelling of the lymphatics seldom takes place. Such cases 
run a comparatively short course — from four to five days — 
and although constitutional symptoms are severe during the 
height of the disease, the throat symptoms being particularly 
distressing, still they are never dangerous in character, and 
sequelae are rare. Of course, albuminuria and even an 
endocarditis may complicate such a condition (see Acute 
Tonsillitis, p. 537). Paralysis never follows pseudo-diphtheria, 
nor is extension to the larynx to be feared, although in the 
severer cases which complicate scarlatina extension to the 
nose and Eustachian tubes frequently takes place. 

Scarlatinal pseudo-diphtheria may become a very serious 
condition. Beside the extension of the membrane just al- 
luded to, sloughing and ulceration may occur, with general 
septic infection, and cellulitis of the neck and suppuration of 
the lymphatics. Such cases present a high mortality rate, 
being equalled in virulence by septic diphtheria only, from 
which they cannot be separated except by a bacteriological 
examination. The membrane develops during the height of 
the fever in the majority of cases, but it may be seen before 
the eruption appears. A diphtheritic sore throat developing 
after the fever has abated, or during convalescence, is more 
likely of bacillary origin than one developed at the height of 
the disease. 

Prognosis. — In estimating the prognosis in a given case of 
diphtheria several factors must be taken into consideration. 
In the first place, we must exclude pseudo-diphtheria, which 
in its primary form offers a good prognosis ; in its secondary 
form (scarlatinal) the prognosis is less favorable and it as- 
sumes more the type of a septic infection. 



ACUTE INFECTIOUS DISEASES. 737 

The age is of importance, as diphtheria is uniformly more 
fatal in infants than in older children. Adults present the 
best chances, but they are more subject to paralytic sequelae. 

The character of the epidemic is of importance, as is also a 
knowledge of the source of infection. Hut this is not always 
reliable, for a most virulent diphtheria may originate from an 
apparently mild diphtheritic sore throat, and vice versa. 

The appearance and distribution of the membrane offer 
valuable suggestions for the prognosis, but here again errors 
are liable to occur. Extensive membranous deposit may ex- 
ist with but slight constitutional disturbances, and scanty 
membrane may be accompanied by grave toxaemia. Neither 
can we foretell if laryngeal involvement, with rapidly de- 
veloping stenosis, will occur. 

The time at which treatment was begun and the patient's 
general condition, therefore, offer the safest guides in deter- 
mining his chances for recovery. So long as the pulse 
remains good and prostration is not pronounced the case 
should not be despaired of. Nasal and laryngeal diphtheria 
are about equally grave, although the nasal type is somewhat 
slower in its course. Septic cases are practically hopeless. 
Other unfavorable symptoms are epistaxis and haemorrhages 
into the subcutaneous tissues ; nephritis ; marked prostration 
and cardiac weakness ; cervical cellulitis. 

In croup the prognosis is more favorable than in secondary 
laryngeal diphtheria, owing to the absence of septic symp- 
toms. 

During convalescence there is danger of paralysis of the 
heart. This may appear as a progressively increasing heart 
weakness, or occur suddenly upon some physical exertion. 
The child is seized with epigastric pain and nausea ; there is 
dyspnoea ; cyanosis; small, irregular pulse and collapse. If 
the first attack does not prove fatal there is usually a recur- 
rence with a fatal issue. 

Broncho-pneumonia occurring with diphtheria is very un- 
favorable ; when complicating croup the case is practically 



738 DISEASES OF CHILDRExX. 

hopeless, as intubation or tracheotomy is of no avail in 
such cases. 

Diagnosis. — There is only one safe means of escaping the 
error of allowing a case of diphtheria to gain headway un- 
recognized until so far advanced as to be self-apparent, 
and that is to examine the throat of every child presented for 
treatment in an acute condition, as a matter of routine. The 
importance of such practice is realized only when we recall 
how trivial the throat symptoms may be in the beginning of 
diphtheria, particularly in a child not able to express itself or 
comprehend its sufferings properly. 

The differential diagnosis rests mainly between pseudo- 
diphtheria and folliculous tonsillitis. Psettdo- diphtheria is ab- 
rupt in onset ; lymphatic swelling is absent in primary cases ; 
fever is high, and the throat is markedly reddened and 
swollen, and there is considerable pain on swallowing ; the 
exudate is purely fibrinous, rarely croupous, and it does not 
tend to spread beyond the tonsils. Secondary cases occur 
during the febrile period of scarlet fever. Paralysis never 
follows, and although septic symptoms may be present the 
specific toxic symptoms of diphtheria are absent. The mem- 
brane is thinner, can be removed without bleeding, and is 
usually of a yellowish color, later becoming dirty. 

In folliculous tonsillitis both tonsils are uniformly swollen 
and covered with small, round, white spots, which are not ad- 
herent to the mucous membrane, but consist of plugs of 
exudation filling up the lacunae of the tonsils, from which 
they can be readily expressed and wiped off. 

Membranous croup is to be differentiated from acute catar- 
rhal laryngitis. (See p. 257.) 

Lastly, it may be said that no diagnosis is complete with- 
out a bacteriological examination, for a case which may ap- 
pear clinically of minor importance may harbor germs of a 
most virulent nature. The differentiation of pseudo-diphtheria 
from true diphtheria becomes also of the greatest importance 
in the matter of isolation, particularly in avoiding the deten- 



ACUTE INFECTIOUS DISEASES. 



'39 



tion of patients suffering from the former disease in isolating 
wards harboring true diphtheria. 

Treatment. — Isolation and siek-room hygiene are to be car- 
ried out on the same plan as recommended under Scarlatina, 
page 650. Children who have been exposed to diphtheria 
should have their throats examined several times daily, and 
be instructed to use a gargle of Permanganate of Potash (1 to 
1,000) three or four times daily. Royer {Therapeutic Gazette, 
April, 1905) insists that the general practitioner does not re- 
sort with sufficient frequency to immunizing doses of anti- 
toxin. He commonly sees at the Philadelphia Municipal 
Hospital a patient admitted seriously ill with diphtheria, 
and in the course of a few days a second or third patient 
from the same house. For a child that has come in direct 
contact with a diphtheria case he recommends one thousand 
units. In my own practice I carry out this principle when- 
ever possible. 

The diet must be of a most concentrated and nutritious 
form, and stimulation is of the greatest importance as soon as 
the toxic influence of the diphtheria virus upon the heart and 
nervous system becomes apparent. A teaspoonful of whisky 
well diluted with water or milk, and administered every two 
to three hours, suffices for the average case ; but where there 
is much prostration and failing heart the quantity must be 
increased accordingly. Absolute rest is to be enjoined during 
convalescence as well as during the disease in all cases show. 
ing cardiac weakness, in order to avert a possible sudden 
death. 

As to local treatment, it can be positively stated that all 
measures in any way giving the patient pain or discomfort 
and requiring physical restraint, or resulting in injury to 
the mucous membrane of the throat, will do nothing ex- 
cepting harm. In infant- a spray of Permanganate of 
Potash (1 to 1,000) given, by means of an atomizer, every two 
or three hours, and in older children a gargle similarly em- 
ployed, has yielded the best results in my hands. Should the 



740 DISEASES OF CHILDREN. 

child be too weak to gargle, a teaspoonful of the solution may 
be given internally every two hours. Alcohol diluted with 
four or five parts of water is also an excellent gargle, but not 
as active as the Permanganate. 

In nasal diphtheria our aim should be to keep the nasal 
chambers as open and free from secretion as possible. A 
douche of Permanganate, i to 2,000, or a warm normal saline 
solution should be given about three times daily, as directed 
on page 19, but the child should be held in the recumbent 
position with its head turned to one side, lying on a Kelly 
pad. 

In laryngeal diphtheria an emetic will give temporary re- 
lief when suffocation becomes imminent, but intubation or 
tracheotomy should not be put off to so late a period. Al- 
though still a matter of dispute, intubation is the preferable 
procedure in the majority of cases. It should always be at- 
tempted first, and, in the event of not offering the most desir- 
able results, tracheotomy may be resorted to as a dernier 
ressort. 

Intubation consists in the introduction of a hard rubber 
tube into the trachea by means of an especially constructed in- 
strument invented by O'Dwyer. In construction it is practically 
nothing more than a handle, to the end of which, at a right 
angle, the intubation tube is temporarily fastened by being 
slipped over an obturator. From this it is released at the 
proper moment by means of a hook-like arrangement that 
is pressed down over the collar of the tube and thus 
pushes it loose from the obturator (Fig. 60). Extubation 
is performed by means of a long, curved, forcep-like in- 
strument with a small beak, as shown in the illustration. 
The beak is inserted into the opening of the tube, the blades 
are separated until the tube clings to the same, and the tube 
is then withdrawn from the larynx. 

The child may be intubated in the erect or in the recumbent 
posture. Personally, I find the recumbent posture preferable, 
and it is employed in the majority of the hospitals that I have 



ACUTE INFECTIOUS DISEASES. 



74-1 



visited. The child is easier to control in this position, and, 
furthermore, the palate tends to fall upward and away from 
the pharynx, thus facilitating the introduction of an instru- 
ment into the larynx. 

The child is prepared by being wrapped in a sheet with 
the arms pinned down to the sides, and the nurse is in- 
structed to hold the legs and trunk, while an assistant 
should be at hand to control the head and keep the 




FIG. 60. — O'DWYKR'S SET OF INSTRUMENTS FOR INTUBATING THE LARYNX. 



mouth-gag in place. A table covered with several thick- 
nesses of blankets and a sheet should be used, and not a 
couch or bed. The mouth-gag is then inserted into the left 
side of the mouth, well back between the molar teeth. The 
proper tube having been selected, according to the age of the 
child, and threaded with a loop of heavy linen thread, it is n<>\\ 
slipped firmly over the obturator of the introducer. The latter 
is lightly held in the right hand, with the thumb upon the knob 



742 



DISEASES OF CHILDREN. 



of the sliding arrangement which releases the tube. The left 
index-finger is passed quickly into the child's pharynx, keep- 
ing to the right side of the mouth, as shown in Fig. 61, and 
the epiglottis is hooked up and held out of the way so that the 
tube may be guided along the middle line, over the base of 
the tongue, and then directly downward and slightly forward 
into the chink of the glottis. In order to give the proper 
direction to the tube the handle of the instrument must be 




FIG. 6l. — CHILD IN PROPER POSITION FOR INTUBATION. INDEX FINGER 

OF LEFT HAND IN MOUTH, FEELING FOR THE EPIGLOTTIS. 

RIGHT HAND HOLDING INTRODUCER WITH TUBE 

READY FOR INTRODUCTION. 



well elevated as soon as the tip of the tube reaches the glottis. 
When the tube has entered the glottis it should be released (by 
means of the slide on the introducer, which is pushed forward 
with thumb), and then buried to its full length into the 
larynx by a gentle push with the left index finger upon the 
collar of the tube. No force is necessary, and undue pressure 
or rough manipulation of the larynx is strictly to be avoided. 
Should the first attempt fail to enter the tube promptly 



ACUTE INFECTIOUS DISEASES. 74-3 

within the glottis, the finger should be removed from the 
pharynx and the child allowed to get its breath before mak- 
ing another attempt. 

The commonest mistake is to pass the tube into the oesoph- 
agus instead of into the larynx. This results from not elevat- 
ing the handle of the introducer sufficiently and failing to 
direct the tube sufficiently forward ; also from getting away 
from the middle line and not keeping closely to the base of 
the tongue. The most reliable landmark by which to find 
the larynx is the arytenoid cartilage. Even when the mucous 
membrane is swollen and false membrane is present this 
knob-like projection can readily be distinguished by the 
index finger. From this we may pass a little inward and for- 
ward in order to find the epiglottis, which must be lifted up 
before the tube can enter the larynx. 

If we have been successful in our attempt, a remarkable 
change soon passes over the child. There will first occur a 
coughing paroxysm, more or less severe, accompanied by 
a characteristic whistling sound which tells us that the tube 
is in the larynx. The cough results from the mechanical 
irritation of the larynx, but this is beneficial, as it usually 
effects the removal of a large amount of tenacious mucus. 
The normal color is restored to the features, and the breath- 
ing, which was rapid and labored, becomes slow and 
tranquil. Usually the child soon goes off into a refreshing 
sleep. As soon as we are convinced that the tube is in place 
and the dyspnoea is relieved, we should cut the string that 
has been attached to the tube (mainly for the purpose of pull- 
ing it out of the oesophagus in an unsuccessful attempt) and 
draw it out of the eyelet in the collar of the tube with the 
left index finger in position upon the collar in order to avoid 
an accidental extubation. 

At the end of the fifth day the tube should be removed. 
The child is held exactly as for intubation and, with the left 
index finger upon the collar of the tube, the beak of the in- 
tubating instrument is guided into the opening of the tube, 



744 DISEASES OF CHILDREN. 

its jaws are opened until they will not slip from the opening, 
and thus gripping the tube it is lifted from the larynx. It can 
then be easily removed from the pharynx with a quick sweep 
of the index finger. 

We must always be ready to re-intubate promptly, however, 
as there may still be sufficient stenosis to render the wearing 
of the tube necessary, or a spasm of the laryngeal muscles 
may follow the removal of the tube, calling for prompt action. 
In rare cases the intrinsic muscles of the larynx become 
paretic from the pressure of the tube, or a cicatricial atresia of 
the larynx may follow upon pressure-ulceration. Fortu- 
nately, the beneficial results from skilfully performed intuba- 
tion so far outshadow its evil results that it has attained to a 
position of universal praise as a life-saver. 

One of the disadvantages of intubation in private practice 
is the possibility that the child may cough up the tube and 
suffocate before the physician can return to the case. It is 
well to remain with every case, or at least close by, for several 
hours after intubating, and if the child shows a tendency to 
cough up the tube it should be removed, whenever possible, 
to a hospital where skilled residents are in charge. Death 
may result under somewhat similar circumstances, even after 
tracheotomy; the child may pull the tube out or it may 
become clogged with membrane. The eminent psediatrist, 
Prof. Caille once remarked, we can do no more than perform 
our duty under these circumstances,' and if we have done the 
best we know how, results may come as they will. 

The membrane may extend down too low to enable the in- 
tubation tube to relieve the dyspnoea, or we may push the 
membrane down ahead of the tube and thus cause suffocation. 
In the latter instance a violent coughing fit will sometimes 
expel both the tube and the membrane. These difficulties 
are mainly encountered in the cases we see late, and I have 
been forced to do tracheotomy several times under such cir- 
cumstances. But we should not wait until the child is suffo- 
cating before intubating. As soon as the breathing becomes 






ACUTE INFECTIOUS DISEASES. 7-L5 

laborious and the epigastric region is plainly drawn in during 
inspiration it is our duty to spare the child not only from the 
suffering, but also from the exhaustion that comes with these 
undue respiratory efforts. 

Nasal intubation as recommended by Xorthrup (New 
York) merits serious consideration. It is indicated in com- 
plete obstruction of the nose by membrane, in young children 
and infants, when this obstruction materially interfers with 
the child's respiration. An old-fashioned English (stiff) 
catheter of the proper calibre is carefully worked through the 
naris until the pharynx is reached ; it is then cut off, allowing 
about an inch to protrude. Tubing one side may give suffi- 
cient relief in the case. Dr. H. M. Gay has reported a case 
which I saw with him and treated in this manner, the infant 
making a good recovery (Tran. Horn. Med. Soc, Penna., 1904 ). 

In all forms of diphtheria, but especially in croup, it is es- 
sential to keep the air of the room moist and at a temperature 
of about 70 F., if this be practicable. The air must, at the 
same time, be kept as rich in oxygen as possible. The 
spraying about the sick-room of hydrogen dioxid, or the 
slaking of lime, is an excellent means of purifying the air. 

It is by no means easy to say just which are our most im- 
portant remedies in diphtheria, as no attempts at differentiation 
have been made in the past between pseudo- and true diph- 
theria, and the errors which so frequently beset the diagnosis 
of membranous croup render it difficult to estimate the exact 
value of the treatment employed. 

The Mercuries, especially the Cyanide, the Bichloride and 
Red iodide; the Bichromate and Permanganate of Potash, the 
Chloride of Lime, Lachesis, Arsenic and Arum triphyllum are 
most closely related to the bacillary variety. Merc. cyan, and 
Kali bich., especially when there is extension to the larynx; 
Arum triph. in the nasal variety, and Arsenic, Lach., Rhus 
tox. and the Chloride of Lime in septic casts. 

The high-grade inflammatory symptoms of pseudo-diph- 
theria call for remedies like Apis, Belladonna, . Ulan thus, 
Phytolacca and Rhus tox. 

48 



746 DISEASES OF CHILDREN. 

Mild diphtheritic anginas yield promptly to the Mercuries \ 
Bell, and Apis. The Red iodide is supposed to be indicated 
when the left tonsil is affected, and the Yellow iodide when 
the right side is involved. Personally, I do not pay any at- 
tention to the side affected, and always give the Red iodide 
the preference over the Yellow. In Belladonna there is con- 
siderable fever and headache, the throat is dry and glistening 
red, and there is pain in swallowing and a sense of constric- 
tion. When these symptoms are present with considerable 
exudate I alternate Belladonna with the Red Iodide of Mer- 
cury. Apis presents more of an oedematous condition, the 
swelling being paler in color and the pains of a stinging char- 
acter, worse on swallowing. 

The most efficient remedies in croup are Bromine, Iodium y 
Kali bichromicum. Liquor calcis chlorinata and Hepar. The 
symptoms of Spongia are more purely catarrhal and spas- 
modic than croupous. Bromine has given me good results 
in a few cases, but since the introduction of antitoxin the 
mortality of croup has been so much reduced that we have 
no right to rely exclusively upon a remedy. Dunham's 
experience {The Science of Therapeutics) with Bcenninghau- 
sen's method of prescribing Aconite, Hepar and Spongia in 
rotation seems to have been of the happiest kind. Neidhard 
obtained good results from his Liq. calcis chlorinata in croup 
as well as in faucial diphtheria, but he frequently alternated 
with Potassium bichromate in the former condition. 

The routine treatment advised by Heysinger (fourn. of 
Ophthal., Otol. and LaryngoL, January, 1892) is of great value 
in all cases of pseudo-diphtheria and in diphtheria with sep- 
tic symptoms. He administers a teaspoonful of a solution of 
Permanganate of potash, one grain dissolved in two and one- 
half to three ounces of water every one to two hours, accord- 
ing to circumstances, in alternation with a teaspoonful of 
Belladonna, five minims of the tincture in three ounces of 
water. The Belladonna relieves the fever and hyperaemia ; 
but with toxaemia it is of no value, and a reined v must be 



ACUTE INFECTIOUS DISEASES. 74-7 

chosen symptomatically {Merc. cyanat., Arsenic, Lachesis, 
Rhus toxicodendron and others). 

The symptoms upon which the remedies applicable to 
diphtheria and croup have been prescribed most frequently 
are the following : 

Acetic acid. — Croup, attended by bright redness of the face. 
From five to ten drops of acetic acid in a half tumblerful of 
water with some sugar ; a teaspoonful every two to three 
hours (C. G. R.). 

Ailanthus. — Scarlatinal diphtheria (diphtheroid) with livid 
and swollen throat. Deep ulcers on tonsils ; the patient 
gradually sinks into a stupor. 

Amnion, carb. — Nasal obstruction and carbonization of the 
blood ; extreme prostration. 

Apis mel. — (Edematous swelling of the fauces, cellular tis- 
sue of neck and of the glottis. Burning and stinging pains 
in throat ; albuminuria. 

Arse?i. — In the later stages, especially in toxic cases with 
marked cardiac weakness ; albuminuria ; irregular fever ; ex- 
treme restlessness. 

Aram triph. — Acrid discharge from the nose excoriating 
the upper lip ; an acrid fluid oozes from the mouth which 
causes the lips to become sore and swollen. The child con- 
stantly picks at the lips and nose, keeping them in a bleed- 
ing condition. There is burning pain in the throat, and the 
breath is very offensive. The membrane spreads up into the 
nares. 

Bell. — Early, especially in cases beginning abruptly with 
pronounced throat symptoms and fever. 

Bromiam. — Croup. Best suited to fair, chubby children, 
and in cases with little or no fever. lodium is recommended 
in brunettes and in the presence of fever. 

Calc. chlor. — The liquor calcis chlorinata was first recom- 
mended by Dr. Neidhard [Diphtheria, Its Nature and Home- 
opathic Treatment, 1867) in diphtheria and croup, and it is 
still a favorite remedy with many practitioners. He em- 



748 DISEASES OF CHILDREN. 

ployed five to fifteen drops of the Liquor in half a tumbler of 
water, giving a teaspoonful every fifteen minutes in urgent 
cases, or only at intervals of several hours in more favorable 
ones. His success was apparently most gratifying. 

Hepar. — Croup. The cough is hard and metallic, with a 
loose edge ; although the child may expectorate, the obstruc- 
tion is not relieved. Croup developing after exposure to 
cold wind. 

Kali bichr. — Croup. Tough, stringy discharge from throat, 
with hoarseness and croupy cough. Also nasal diphtheria 
with a similar discharge from nose ; extension up into the 
Eustachian tube. The best remedy to control the excessive 
secretion in croup cases even after antitoxin has been ad- 
ministered. 

Lachesis. — The symptoms are intense, although the throat 
lesion may be apparently slight (toxic cases). The membrane 
is grayish or becomes black, (hsemorrhagic) and is surrounded 
by a purplish areola ; the throat is purple, not bright red as 
in Apis (Allen) ; the cellular tissue of the neck is infiltrated 
and the skin presents a livid hue. Hyperesthesia about the 
throat is a most characteristic symptom, and the patient must 
have all garments as loose as possible in this region. 

According to Allen, in all cases requiring Lachesis there is 
usually sharp pain shooting from the throat up into the ears. 
Cardiac symptoms may also be prominent, the patient being 
unable to get his breath unless propped up in bed, etc. 

Merc, cyanatus. — Adynamic cases with abundant mem- 
brane displaying a tendency to travel down into the larynx. 
" Adynamic fever and collapse already in the commence- 
ment." (Von Villers.) According to Allen it is also of 
service in nasal cases with profuse debilitating sweat from 
the slightest exertion. The Cyanide of Mercury is undoubt- 
edly a truly homoeopathic remedy to toxic diphtheria, pro- 
ducing the extreme adynamia observed in these cases as well as 
gangrene of the velum palati and fauces (Beck). Of late the 
old school has been making use of it, a series of eighty-one 



ACUTE INFECTIOUS DISEASES. 74-9 

cases of diphtheria with but one death being reported by 
Luddeckens-Leignitz {Aerztliche Rundschau, 1896, No. vi). 
He also uses it in scarlet fever, whether complicated by mem- 
branous angina or not. His usual dose was a teaspoonful of 
a 1 to 10,000 solution every hour (fourth decimal dilution). 

Merc. jod. ruber. — Membrane begins on the tonsils ; pain- 
ful swelling of lymphatics ; the tonsils are swollen and the 
palate elongated ; the patches are irregular in outline and of 
a dirty yellowish color ; tongue heavily coated and flabby ; 
offensive breath. The Yellow iodxide, it is claimed, affects the 
right side and partakes more of the general characteristics of 
Mercury, while the Red iodide displays more of the action 
of Iodine. I do not believe, however, that there is sufficient 
clinical experience to give the proper authority to this 
distinction. 

Phytolacca. — Much pain and swelling in the throat. The 
mucous membrane is of a bluish-red color and is covered 
with grayish ulcers. 

Rhus tox. — The throat appears as if varnished (glistening), 
and of a dusky red color. Swelling of the lymphatics and 
cellular tissue of the neck is marked. There is great rest- 
lessness and prostration, with aching in every joint. vSeptic 
cases. 

Post-diphtheritic Paralysis. — The most useful remedies 
are Gelsemium, Causticuni, Phosphorus, Cocculus and Nux 
vomica. Strychnine is extensively used by the old school, 
but many of its best authorities are in doubt as to any specific 
influence exerted by it over the condition, relying more on 
a general tonic treatment and galvanism. Stiegele [Allg. 
Horn. Zeitung, Dec, 1901) reports a case in which Phosphorus, 
5th dilution, was prescribed with rapid improvement, un- 
doubtedly due to the drug's action, on the following symptoms : 
Cardiac weakness with spells of palpitation ; marked debility 
of the extremities ; uncertain gait, and formication in the 
hands and feet. Causticum is most useful in laryngeal and 
ocular paralysis. Cardiac weakness with blueness of the lips 
and ptosis call for Gelsemium. 



750 DISEASES OF CHILDREN. 

Serum Therapy. — The antidotal treatment of diphtheria, 
by means of the hypodermatic injection of the blood-serum 
of horses, previously immunized to the toxins of diphtheria 
by being subjected to progressively increasing doses of the 
same, has furnished us with the most valuable means at our 
command for the cure of this much dreaded disease. Not 
only is the serum, popularly known as diphtheria antitoxin 
serum^ capable of antidoting the systemic disturbances 
belonging to diphtheria, but it also exerts a specific in- 
fluence upon the local manifestations. Furthermore, it 
has been conclusively demonstrated that an artificial im- 
munity against the disease can be obtained from a com- 
paratively small dose. This, however, is of a transient 
nature, only lasting for a period of a few weeks, but it 
nevertheless indicates the strong antagonism which ex- 
ists between the serum and the toxin. The overwhelming 
evidence in favor of this form of treatment in diphtheria, 
based on statistics coming from both Europe and America, 
and from private practice as well as from large hospitals for 
contagious diseases, should expel all doubt as to its efficacy. 
When we consider that the clinical manifestations of diph- 
theria are purely of toxic origin, requiring antidotal treat- 
ment as well as any other case of poisoning, be it a snake 
bite, arsenic- or opium-poisoning, we should gladly take advan- 
tage of such a potent remedy, and by using it in conjunction 
with judicious local measures and remedies chosen on indica- 
tions requiring special consideration, we may hope to still 
further lower the death-rate so materially changed within the 
last decade. 

The sphere and scope of antitoxin must not be superficially 
considered, for it has both its limitations and characteristic in- 
dications, as well as any other remedial agent of positive value. 
Again, the limit of its action is to antidote the toxins circu- 
lating in the blood and check the local process ; it has no 
curative effect beyond this, which is simply the creation of 
an artificial immunity. Upon the parenchymatous changes 



ACUTE INFECTIOUS DISEASES. 



751 



in the heart, kidneys and other internal organs, and the speci- 
fic changes in the nervous system, it has not the slightest influ- 
ence. Consequently its efficacy becomes less and less positive 
as the disease is allowed to progress without efforts to check it, 
and the occurrence of diphtheritic paralysis cannot be averted 
in a system which has already been saturated with the toxins, 
even if antitoxin be used late in such a case with otherwise 
favorable results. In pseudo-diphtheria and in septic cases it is 
useless. The use of antitoxin in such cases has given it 
many a black eye, if I may use such a term. If a serum is 
at all to be used here, it must be one capable of neutralizing 
streptococcus toxins. A slight admixture of streptococci 
cannot be said to contraindicate the employment of antitoxin, 
as the bacillus produces the most important disturbances in 
these cases ; but if there be considerable angina and adenitis, 
fever, headache and other symptoms of a similar nature, the 
best results are obtained by using the Belladonna and Per- 
manganate of potash combination in conjunction with the 
antitoxin. 

A perfect case for antitoxin is one in which the bacillus is 
found in practically pure culture in the throat and the symp- 
toms correspond to the description of a typical case of uncom- 
plicated diphtheria as depicted above. Membranous croup 
of purely bacillary origin is also most positively benefitted by 
it. As pseudo-membranons laryngitis only exceptionally re- 
sults from other than diphtheritic infection, the exceptions 
being those rare cases accompanying malignant scarlatina, it 
possesses in antitoxin a remedy for which we should indeed 
be thankful. 

According to the report of the collective investigation of 
the American Pediatric Society {New York Medical Record \ 
May 15, 1897), the mortality among cases of laryngeal diph- 
theria operated upon was reduced to 27.24 per cent., early 
statistics of intubation in pre-antitoxin days showing only 27 
per cent, recovery. The number of cases requiring operation 
was also greatly reduced, being 39 per cent, with the use of 






752 DISEASES OF CHILDREN. 

antitoxin, and about 90 per cent, without it. In a former re- 
port it was shown that the average mortality from faucial 
diphtheria in private practice was about 12 per cent., but 
among the cases which received antitoxin within the first 
three days it was only 7.3 per cent. Prof. Goodno, who was 
one of the first in our school to champion the serum therapy 
of diphtheria, reported two hundred and seventeen cases of 
diphtheria seen in private practice (mostly in consultation) 
with nine deaths, a mortality of about 4 per cent. (Hahne- 
mannian Monthly, June, 1901). Baginsky treated eighty-two 
consecutive cases with antitoxin at the Friedrich's Hospital 
in Berlin, with a mortality of 12.2 per cent. Immediately 
following this series, one hundred and three cases were treated 
without antitoxin, and the mortality rose to 53.4 per cent. 
After this, antitoxin was resumed, and out of one hundred 
and twenty-four cases only 11.3 per cent. died. Clubbe {Brit- 
ish Medical Journal, Oct., 1897) reported a parallel series of 
three hundred cases of diphtheria, treated with and without 
antitoxin, at the Sydney Children's Hospital. The diagnosis 
was confirmed bacteriologically in all cases. Of those treated 
without the serum, 52.7 per cent, died; one hundred and 
ninety-nine required tracheotomy, with a mortality of 67.8 
per cent. The mortality was reduced to 20 per cent, by the 
employment of serum injections, and among this series only 
one hundred and twenty-nine required tracheotomy, with a 
mortality of 37.9 per cent. Since antitoxin has been used 
more heroically even better results are obtained. Thus, in 
Boston, McCollom (City Hospital, South Dept.) gradually 
brought his mortality rate down to about 11.5 per cent, in 
1903, from 14.5 per cent, in i895~'96, — the early period of 
serum therapy. In intubation cases it fell from 64.5 per cent, 
in 1896 to 26.6 per cent, in 1903. Statistics could be cited 
ad infinitum, but as they all practically indicate the same 
beneficial results from the antitoxic treatment the foregoing 
will suffice. 

Accurate rules for dosage cannot be laid down for all cases > 



ACUTE INFECTIOUS DISEASES. 753 

nevertheless there are certain rules of procedure that 
apply to the average case. In the last few years the 
views concerning the dosage of antitoxin have changed con- 
siderably, especially since McCollom, has so clearly demon- 
strated the harmlessness of large doses and their advantage 
over the smaller dose. 

The following doses are in use at the Municipal Hospital 
(Philadelphia). Purely tonsillar exudate (single), 2,500 units ; 
the same, double, 5,000 units. Tonsillar exudate with in- 
volvement of pillars and uvula and larynx, 7,500 to io,oco 
units; nasal and any other part involved, 7,50c to 10,000 
units ; laryngeal, 7,500 to 10,000 units. 

Repeat the dose in each case in from twelve to twenty-four 
hours, depending upon severity of case and signs of improve- 
ment (Rover, loc. ctt.). 

I doubt the necessity for such doses in private practice, es- 
pecially when we see the case early. In mild cases, seen early, 
2,000 units usually suffice. In the severe cases we should begin 
with 4,000 units and repeat the injection at the end of twelve 
hours if the progress of the disease has not been arrested. If 
the patient is worse I recommend double the initial dose 
(8,000 units) to be given at this time. If improvement sets 
in, but the membrane does not promptly come away, the 
injection should be repeated at the end of twenty-four to 
forty-eight hours. 

In laryngeal cases it is best to give 4,000 units at once on 
suspicion. If, in the meantime, we have been able to estab- 
lish the diagnosis of laryngeal diphtheria we should repeat the 
dose at the end of twelve hours if the case is no worse, and 
twice this dosage if stenosis is progressing. A third injection 
is, as a rule, unnecessary and it may not even become neces- 
sary to intubate. This I have seen repeatedly. 

In children under two years of age the- dose- should not ex- 
ceed 3,000 units in the severer cases. In mild cases, which 
are seen early, 1,500 units is the max i mum dose usually re- 
quired. In order to obtain the best results, therefore, anti- 



754 DISEASES OF CHILDREN. 

toxin must be used early and insufficient potency to neutralize 
the toxins in the blood, repeating the dose if the action of the 
first one does not yield the desired results after a reasonable 
length of time. 

The method of injection is simple. A site at which the skin 
is loose and not highly sensitive (preferably the axillary region 
or that of the shoulder-blade) is cleansed preparatory to the 
injection and the child is laid on its side. The injection is 
then made in the usual manner, and in order to avoid fright- 
ing the child unduly, we should keep the syringe out of sight 
and not make elaborate preparations before the unfortunate 
patient. Again, by injecting slowly, much unnecessary pain 
is avoided and loss of serum is likely to be less than by too 
hurried a procedure. Since the improvements in the pre- 
paration of serum have given us the same in a highly con- 
centrated form, the necessity for employing an especially 
large syringe is done away with. Again, the sera on the 
market are put up in convenient packages, combining a con- 
tainer and aseptic syringe. However, it is well to have a 
special hypodermic syringe (one of 5 c.c. capacity) for this 
purpose, in order to insure of its being in readiness at all 
times. The needle should be boiled before inserting it under 
the skin, and the barrel of the syringe cleansed with an anti- 
septic solution before and after using. By carrying out a per- 
fectly aseptic technique and employing a concentrated form 
of serum the local and general disturbances attributed to 
antitoxin will seldom be seen. 

The beneficial effect of the serum upon the local and con- 
stitutional manifestations of the disease is noteworthy. First 
of all, there is a drop in the temperature. Repeated examin- 
ations of the throat will indicate that the membrane has 
ceased to spread, it becomes paler and cleaner in appearance, 
and at the end of twenty-four hours begins to loosen and 
shrivel. Within forty-eight hours an extensive membrane 
may have almost entirely disappeared, leaving behind only 
small fragments of the more firmly attached portions. Laryn- 



ACUTE INFECTIOUS DISEASES. 755 

geal stenosis is sometimes relieved sufficiently within a few- 
hours to render intubation unnecessary. Nasal obstruction 
is relieved in a similar manner. As regards the constitu- 
tional symptoms, there is a rapid change from a condition of 
a most serious illness to a comparatively benign one. How r ever, 
as said before, antitoxin does not prevent sequelae, nor does it 
undo the mischief which has resulted from the action of the 
toxins upon the organs and tissues of the body. For this rea- 
son it is always wise to combine constitutional treatment with 
the antidotal treatment, with the object of counteracting these 
pathological processes and preventing sequelae. 

GLANDULAR FEVER. 

This disease w<as first described by PfeifTer {Jahrbuch fur 
Kinderheilk., Band, xxix., 1889) and his observations have 
since been verified by both Continental and American ob- 
servers. 

The etiology is still obscure, but it is undoubtedly infec- 
tious, as it usually occurs in house-epidemics. West (Archives 
of Pediatrics, Dec, 1896) reported an epidemic of ninety-six 
cases as having occurred in eastern Ohio. It is most fre- 
quently seen between the ages of two and eight, and in the 
fall and winter months (Filatow). 

The onset is abrupt, as a rule, the temperature reaching 
103 F., or over. The child complains of loss of appetite, 
difficulty in swallowing, and pain on attempting to move 
the head from side to side. The bowels are constipated, and 
vomiting may be present. In conjunction with these symp- 
toms there is coryza, injection of the mucous membrane of 
the throat, and slight difficulty in swallowing. The patho- 
gnomonic symptom is swelling of the glands of the neck, 
those situated just behind the point of origin of the sterao- 
cleido-mastoid muscle being most prominently enlarged. 
They are painful to the touch, and by careful palpation we 
can make out the nodular character of the swelling, pointing 
to the involvement of a series of individual glands. This 



756 DISEASES OF CHILDREN. 

condition, in conjunction with the movability of the swelling, 
offers a ready distinction between glandular fever and mumps. 

The fever may last for only a few days, or it may be pro- 
longed to eight or ten days. In such case enlargement of the 
spleen and liver, scanty urine, and even albuminuria, may be 
observed. The swelling does not terminate in suppuration, 
but it may persist for some time after the fever has abated. 
I have seen it last for several weeks, with, however, gradual 
restoration to normal in every respect. 

The prognosis is good. The diagnosis may require differ- 
entiation from acute simple adenitis, mumps, and diphtheria. 
The resemblance between the last two conditions is purely 
superficial, but they should be excluded in order to avoid error. 

The chief remedies are Belladonna and Mercuriits. 



INDEX 



Abscess, peritonsillar, 541 
retropharyngeal, 546 
symptoms, 547 
therapeutics, 54S 
treatment, 548 
Acetone in gastric contents, 142, 165 
Aceton-uria, 165 

Acid hydrochloric, in gastric con- 
tents, 143 
Acidometer, 143 
Adenitis, acute, 591 
tuberculous, 591 
acute, 591 
cervical, 591 
chronic, 591 
local, 591 
mesenteric, 592 
therapeutics, 592 
tracheo-bronchial, 591 
treatment, 592 
surgical, 594 
Adenoid vegetations, 559 
diagnosis, 562 
pathology, 560 
symptomatology, 561 
therapeutics, 565 
treatment, 564 
surgical, 565 
Airing, 12 

Albumen water, 106 
Albuminuria, cyclic, 365 
prognosis, 366 
therapeutics, 367 
treatment, 366 
idiopathic, 365 
orthostatic, 365 
Alcohol baths, 109 

indications for use of, 70 
Allenbury's foods, no 
Amoebic dysentery. 222 



Anaemia, 422 

blood in, 424 
pernicious, 426 
blood in, 427 
diet in. 427 
etiology, 426 
symptomatology, 426 
therapeutics, 428 
treatment. 427 
psendo-leukaemic, 432 
secondary, 423 
simple. 423 

therapeutics. 42S 
treatment, 427 
splenic (v. leukaemia), 423, 431 
symptomatic, 423 

therapeutics, 429 
therapeutics, 428 
with leucocytosis, 424 
Analysis of cerebro-spinal fluid, 4t>2 
of gastric content-, 142 
in cyclic vomiting. 165 
in marasmus, 62b 
of milk, cow's, 83 

human. 80 
of stools, 188 
of urine, 66 
Angina pectoris, 3^2 
Ankle clonus, 48 

Anomalies of heart (v. heart anom- 
alies). 338 
Antitoxin, diphtheria, 750 
dosage, 752 
statistics, 732 

technique of injection, 734 
tetanus, 116 
Aortic regurgitation 

stenosis, 358 
Aphthae, Bednar's, 130 
epizooticae, 130 



758 



INDEX. 



Aphthous stomatitis (v. stomatitis) 

129 
Apoplexy in newborn, 114 
Appendicitis, 236 

diagnosis, 238 

symptomatology, 237 

therapeutics, 239 

treatment, 238 

varieties, 237 
Arteritis, umbilical, 115 
Arthritis deformans, 612 
Arthritism, 569 
Artificial foods, 109 
Asphyxia, extra-uterine, 112 

intra-uterine, 112 

neonatorum, 112 
treatment, 113 

sudden death from, 123 
Asses' milk (v. milk), 79 
Astasia abasia, 506 
Asthma, 267 

diagnosis, 269 

of Millar, 254 

symptomatology, 268 

therapeutics, 269 

thymic, 254 

treatment, 269 

varieties, 267 
Atavism, 41 
Ataxia, family, 519 
diagnosis, 521 
prognosis, 521 
symptomatology, 520 

hereditary cerebellar, 520 
Atelectasis in newborn, 123 
Athrepsia (v. marasmus), 160, 624 
Atresia of stomach, 169 
Atrophy of liver, acute yellow, 179 
Aura, epileptic, 480 
Auscultation, general methods, 59 

in diseases of stomach, 140 

Babinski's sign, 48, 439 
Bacteria in milk, 100 

of intestinal tract, 193 
Baked flour, 108 



Barley water in modified milk, 94, 

105 
Barlow's disease (v. scurvy), 584 
Bathing, 9 
Baths, alcohol, 109 

bran, 18 

cold, 18 

hot, 18 
Bednar's aphthae, 130 
Beef juice, 95, 106 

tea, 106 
Black measles, 637 
Blood corpuscles, morphology, 418 

diseases of, 418 

erythrocytes, 418 
determination, 421 

examination, 421 

in amoebic dysentery, 223 

in anaemia, 424 

in chlorosis, 425 

in leukaemia, 431 

in malaria, 694 

in meningitis, cerebro-spinal, 690 

in pernicious anaemia, 427 

in pneumonia, 288 

in rheumatism, 607, 612 

in rickets, 580 

in rubeola, 640 

in typhoid fever, 708 

leucocytes, 419 

determination, 422 
differential count, 422 

pressure in childhood, 335 

specific gravity, 418 
determination, 422 
Boils (v. furunculosis), 405 
Bowels, regulation, 12 
Brain, diseases of, 450 
Brandy, use of, 109 
Bright's disease (v. nephritis, chron- 
ic), 373 
Broadbent's sign, 47 
Bronchiectasis, 262, 265 
Bronchitis, acute, 259 
diagnosis, 262 
pathology, 260 
symptomatology, 261 



INDEX. 



759 



Bronchitis, therapeutics, 263 
treatment, 262 
varieties, 260 
capillary, 262 
chronic, 264 
pathology, 264 
symptomatology, 265 
therapeutics, 265 
treatment, 265 
Broncho-pneumonia, acute, 270 
diagnosis, 278 
etiology, 270 
pathology, 272 
prognosis, 277 
symptomatology, 275 
therapeutics, 279 
treatment, 278 
Broths, 106 
Buhl's disease, 116 

Calculi, biliary, 179 

renal, 382 

symptomatology, 382 
therapeutics, 383 
treatment, 383 

vesical (v. cystitis), 384 
Camphor, uses of, 71 
Cancer of stomach, 176 
Cane-sugar in modifying milk, 88, 90 
Carpo-pedal spasm, 490 
Case, methods of taking, 41 
Catarrh, gastric, acute, 152 

gastric, chronic, 158 

gastro-intestinal, chronic, 223 

intestinal, acute, 209 
Cephalalgia (v. headache), 527 
Cephalhematoma, 113 
Cerebral palsy (v. palsy) , 510 
Cerebro-spinal fever, epidemic, 684 

fluid, analysis of, 462 

meningitis, epidemic, 684 
Chapin dipper, 91 
Chapin's method of modifying cow's 

milk, 83, 91 
Charcot-Leyden crystals, 191 
Chicken broth, 106 
Chicken-pox (v. varicella), 665 



Childhood, periods of, 30 
Chlorosis, 424 

blood in, 425 

etiology, 424 

prognosis, 425 

symptomatology, 424 

therapeutics, 428 

treatment, 427 
Cholelithiasis, 179 
Cholera infantum, 204 

diagnosis, 207 

etiology, 204 

pathology, 205 

symptomatology, 205 

therapeutics, 218 

treatment, 214 
Chondrodystrophia foetalis, 572 
Chorea, 492 

cardiac, 498 

diagnosis, 498 

diet, 499 

etiology, 492 

in rheumatism, 612 

laryngeal, 495 

paralytic, 496 

pathology, 494 

post-hemiplegic, 495 

prognosis, 498 

symptomatology, 495 

therapeutics, 499 

treatment, 499 
Chvostek's symptom, 490 
Cirrhosis of liver, 180 
Clinical examination, methods, 30 
Clothing, 10 
Club-foot, 520 
Codliver oil, 109 
Cold, therapeutics of, 17 
Colic, 138 

renal, 382 
Colitis, follicular, 212 

ileo-, acute, 209 

membranous, 210, 213 

diagnosis, 213 
Colli-,' law, 617 
Colostrum, So, 98 
Condensed milk, 1 10 



760 



INDEX. 



Constipation, 231 

symptomatology, 231 

therapeutics, 233 

treatment, 232 
Constitutional diseases, 567 

remedies, 75 
Consumption (v. tuberculosis) , 297 

galloping, 298 
Contraction of stomach, 170 
Convulsions (v. eclampsia), 473 

epileptic (v. epilepsy), 478 
Convulsive affections, 473 
Costiveness, 231 
Cowpox (v. vaccinia), 661 
Cow's milk (v. milk, cow's), 83 
Coxalgia, 506 
Craniotabes, 46 
Cremometer, 81 
Cretinism, 448 

sporadic, 449 
Croup, membranous, 726, 733 

spasmodic (v. laryngitis, acute ca- 
tarrhal), 256 
Cyclic albuminuria (v. albuminu- 
ria), 365 

vomiting, 164 
Cystitis, 384 

symptomatology, 385 

therapeutics, 386 

treatment, 386 

varieties, 385 

Dactilitis, 620 
Deaf-mutism, 448 
Deformities of heart, 337 
Dementia, 444 
Dentition, 124 
therapeutics, 126 
treatment, 126 
Development, in infancy, 32 

muscular, in infants, 36 
Diabetes insipidus, 378 

diagnosis, 378 

etiology, 378 

pathology, 378 

prognosis, 378 

symptomatology, 378 



Diabetes, therapeutics, 379 
treatment, 379 
mellitus, 379 
diagnosis, 380 
diet, 380 
pathology, 380 
symptomatology, 380 
therapeutics, 381 
treatment, 380 
Diacetic acid in gastric contents, 

142, 165 
Diacetonuria, 165 
Diarrhoea, acute infectious, 201 
etiology, 202 
diet, 203 
chronic, 223 
diagnosis, 225 
pathology, 224 
prognosis, 225 
symptomatology, 224 
therapeutics, 226 
treatment, 226 
fermental, 201, 207 
simple (v. indigestion, acute in- 
testinal), 196 
therapeutics, 218 
Diastase, 107 
Diathesis, types of, 38 
Diazo-reaction, 714 
Diet (v. feeding), 77 
at various periods, 96 
in albuminuria, 366 
in anaemia, 427 
in cholera infantum, 216 
in chorea, 499 
in constipation, 232 
in cystitis, 386 
in diabetes mellitus, 380 
in diarrhoea, acute, 216 

chronic, 226 
in epilepsy, 482 
in gastralgia, 168 
in gastritis, acute, 155 

chronic, 161 
in hepatic diseases, 181 
in ileo-colitis, 216 



INDEX. 



761 



Diet, in indigestion, gastric, 147 

intestinal, 198 
in lithaemia, 570 
in marasmus, 630 
in nephritis, acute, 372 

chronic, 377 
in renal calculi, 383 
in rheumatism, 613 
in rickets, 582 
in scarlatina, 652 
in scrofula, 592 
in scurvy, 586 
in tuberculosis, intestinal, 230 

pulmonary, 312 
in typhoid fever, 716 
in vomiting, cyclic, 166 
Digestion in infancy, 183 
Digitalin, use of, 71 
Dilatation of stomach, 170 
Diphtheria, 725 
antitoxin, 750 
diagnosis, 738 
diet, 739 
etiology, 725 
intubation in, 740 
laryngeal, 733 

treatment, 740 
nasal, 732 

treatment, 740 
paralysis after, 749 
pathology, 727 
prognosis, 736 
pseudo-, 725, 734 

clinical course, 735 

scarlatinal, 736 
symptomatology, 628 
therapeutics, 745 
tracheotomy in, 740, 744 
treatment, 739 
Diphtheroid, 725, 734 
Diplegia, 513 

Diseases, acute infectious, 635 
of blood, 418 

brain, 450 

ear, 530 

heart, 332 

intestines, 183 

49 



Diseases of kidneys, 364 
liver, 177 
meninges, 450 
mouth, 124 
nervous system, 438 
new-born, 31, 112 
nose, 530 
peritonaeum, 248 
respiratory tract, 254 
skin, 393 
stomach, 137 
throat, 530 
urinary organs, 364 
Dosage of remedies, 74 
Dysentery, 209 
amoebic, 222 
pathology, 209 
symptomatology, 211 
therapeutics, 222 
treatment, 214 
Dyspepsia (v. gastric indigestion, 
acute), 146 
nervous (v. gastric indigestion, 
chronic), 149 
Dystrophy, idiopathic muscular, 517 
facio-scapulo-humeral, 518 
infantile, 518 
juvenile, 517 
pathology, 517 
peroneal, 518 
therapeutics, 519 
treatment, 518 

Ear diseases, 530 
Eclampsia, 473 

diagnosis, 475 

prognosis, 475 

symptomatology, 474 

therapeutics, 476 

treatment, 47b 
Ectocardia, 338 
Eczema, 394 

definition, 394 

diagnosis, 397 

erythematosnm, 394 

etiology, 395 
intertrigo, 394 



762 



INDEX. 







394 



319 



348 



Eczema, papillosum, 394 
pathology, 397 
prognosis, 399 
pustulosum, 394 
squamosum, 395 
symptomatology , 
therapeutics, 400 
treatment, 399 
vesiculosum, 394 

Efneurage, 29 

Eggnog, 109 

Eggs, 95 

Emphysema, 318 
symptomatology 
therapeutics, 319 
treatment, 319 

Empyema (v. pleurisy 

Endocarditis, 346 
foetal, 338 
in rheumatism, 610 
malignant, 350 
symptomatology 
therapeutics, 351 
treatment, 350 - a 
ulcerative, 350 

Enemata, 27 

Enteroclysis, 28 

Enteroptosis, 170 

Enuresis, 387 
prognosis, 388 
symptomatology 
therapeutics, 389 
treatment, 388 

Epilepsy, 478 

diagnosis, 481 
etiology, 478 
hystero-, 504 
Jacksonian, 474 
prognosis, 481 
symptomatology , 
therapeutics, 483 
treatment, 482 

Epiphysitis, 618 

Erysipelas, new-born, 

Erythema, 403 
caloricum, 404 
efinition, 403 



319 



387 



479 



ii5 



Erythema, intertrigo, 404 

medicamentosum, 405 

scarlatinoides, 404 

simplex, 403 

therapeutics, 405 

toxic, 403 

traumaticum, 404 

treatment, 405 

venenatum, 404 
Exanthemata, 635 
Exercise, 13 

Faeces (v. stools) , 184 

Family ataxia (v. ataxia), 519 

Farinaceous food, 94 

Fats as food, 109 

Fatty degeneration, acute, 116 

Feeding (v. diet), 77 

adjuvant foods, 105 

artificial foods, 105 

forced (v. gavage) , 26 

infant, 77 

intervals, 98 

quantity of food, 98 

time, 11 

variation in foods, 97 
Fever, cerebro-spinal, 684 

glandular (v. glandular fever) , 755 

malarial (v. malaria) , 694 

spotted, 684 

typhoid (v. typhoid fever), 700 
Flour, baked, 108 
Fcetal endocarditis, 338 
Fontanels, closure of, 36 
Formulae for modifying cow's milk, 

93 
Friedreich's disease (v. ataxia), 519 
Fruit juices, 109 
Functional heart diseases (v. heart 

diseases) , 362 
Furunculosis, 405 

diagnosis, 406 

symptomatology, 406 

therapeutics, 407 

treatment, 407 

Gallstones, 179 



INDEX. 



763 



Gastralgia, 167, 527 
diagnosis, 167 
etiology, 167 
in rheumatism, 612 
symptomatology, 167 
therapeutics, 168 
treatment, 168 
Gastric contents, analysis of, 142 
spasm, congenital, 173 
ulcer, 175 
Gastritis, acute, 151 
afebrile, 153 
catarrhal, 152 
corrosive, 152 
diagnosis, 155 
etiology, 151 
febrile, 153 
follicular, 153 
membranous, 153 
pathology, 152 
prognosis, 155 
symptomatology, 153 
therapeutics, 156 
treatment, 155 
chronic, 158 
atrophic, 160 
diagnosis, 161 
etiology, 158 
mucous, 160 
pathology, 159 
prognosis, 161 
simple, 160 
symptomatology, 159 
therapeutics, 162 
treatment, 161 
Gastro-enteric intoxication, acute, 
207 
diagnosis, 208 
prognosis, 208 
therapeutics, 218 
treatment, 214 
Gastro-intestinal catarrh, chronic, 

223 
Gavage, 15, 17, 26 
German measles (v. rubella) , 656 
Glandular fever, 755 
diagnosis, 756 



Glandular fever, etiology, 755 

prognosis, 756 

symptomatology, 755 

therapeutics, 756 

treatment, 756 
Globus hystericus, 504 
Glottis, spasm of, 254 
therapeutics, 255 
Glycosuria, 380 

Gonorrhoea (v. vulvovaginitis) , 390 
Gonorrhoea, newborn, 121 
Grand mal, 478 
Grape juice, 95 
Grippe (v. influenza), 678 
Growth in infancy, 32 

Haeniatoma of sterno-mastoid mus- 
cle, 113 
Haematuria, 367 
in scurvy, 585 
Haemoglobin, determination, 421 
Hemoglobinuria, 367 

acute, in newborn, 117 
Haemophilia, 433 
pathology, 434 
prognosis, 434 
therapeutics, 435 
treatment, 435 
Haemoptysis, 306 

Haemorrhage, gastro-intestinal, new 
born, 120 
intracranial, newborn, 114 
Haemorrhagic diathesis (v. haemo- 
philia), 433 
Hammer-toe, 520 
Headache, 527 
diagnosis, 528 
etiology, 528 
symptomatology, 528 
therapeutics, 529 
treatment, 528 
Head-nodding 1 \. spasmus nutans . 

5oi 
Heart anomalies, congenital, 338 
diagnosis, 341 
symptomatology, 340 
therapeutics, 342 
treatment, 342 






764 



INDEX. 



Heart, defect of septum, 339 


Hysteria, accidents, 504 


congenital, 337 


diagnosis, 508 


deformities, 337 


prognosis, 508 


diseases of, 332 


stigmata, 503 


disease, chronic valvular, 354 


symptomatology, 503 


functional, 362 


therapeutics, 509 


murmurs, 336 


treatment, 509 


patent ductus arteriosus, 339 


Hystero-epilepsy, 504 


patent foramen ovale, 339 




stenosis of pulmonary artery, 339 


Icterus, catarrhal, 178 


symptomatology, 362 


neonatorum, 119 


therapeutics, 363 


physiological, 119 


treatment, 363 


Idiocy, 445 


valvular defects, 340 


by deprivation, 448 


Heat, therapeutics of, 17 


cretinoid, 449 


Hemicrania, in rheumatism, 612 


eclampsic, 446 


Henoch's purpura, 436 


epileptic, 447 


Hepatitis, 182 


genetous, 445 


Hernia, incarcerated, 235 


hydrocephalic, 446 


strangulated, 235 


inflammatory, 447 


History, family, 41 


microcephalic, 446 


of case, taking of, 41 


paralytic, 447 


Hives (v. urticaria), 409 


sclerotic, 447 


Hodgkin's disease (v. leukaemia), 


syphilitic, 447 


432 


therapeutics, 450 


Human milk (v. milk), 77 


traumatic, 448 


Hutchinson's teeth, 620 


treatment, 449 


Hydrocephaloid, 206 


Ileo-colitis, acute (v. dysentery) 


therapeutics, 222 


209 


Hydrocephalus, 468 


catarrhal, 211 


acute (v. meningitis, tubercular), 


Imbecility, 445 


453, 468 


Impetigo contagiosa, 408 


chronic, 468 


definition, 408 


diagnosis, 470 


diagnosis, 409 


external, 468 


etiology, 409 


ex vacuo, 468 


prognosis, 409 


internal, 468 


symptomatology, 408 


symptomatology, 469 


therapeutics, 409 


therapeutics, 472 


treatment, 409 


treatment, 471 


simplex, 407 


Hydrotherapy, in typhoid, 717 


definition, 407 


Hygiene, 9 


diagnosis, 408 


Hyperchlorhydria, 151 


etiology, 408 


Hyperostosis tibialis, 620 


prognosis, 408 


Hypertrophy, tonsils (v. tonsils, 


symptomatology, 407 


hypertrophy), 543 


treatment, 408 


Hysteria, 502 


Impurities in milk, 83 



INDEX. 



765 



Inanition, acute, 628 
Incubators, 14, 16 
Indicanuria, 483 
Indigestion, acute gastric, 146 
etiology, 146 
symptomatology, 147 
therapeutics, 149 
treatment, 147 
acute intestinal, 196 
diagnosis, 198 
etiology, 196 
symptomatology, 197 
therapeutics, 199 
treatment, 198 
chronic gastric, 149 

symptomatology, 150 
infantile, 151 
Infancy, development in, 32 
growth in, 32 
periods of, 30 
Infantile convulsions (v. eclampsia) 

473 

paralysis (v. poliomyelitis), 515 
Infantilism, 447 
Infant feeding (v. feeding), 77 

morbidity, 30 

mortality, 31 
Infants, delicate, 14 

premature, 14 
Infectious diseases, acute, 635 
Influenza, 678 

abdominal, 680 

catarrhal, 680 

cerebral, 680 

diagnosis, 681 

etiology, 679 

neuralgic, 680 

prognosis, 681 

symptomatology, 679 

therapeutics, 682 

thoracic, 680 

treatment, 682 
Inhalation of steam, 2 1 
Injection, rectal, 27 
Insanity, 441 

circular, 443 

delusional, 443 



Insanity, epileptic, 442 

hysterical, 443 

masturbation, 444 

morbid fears, 444 

moral, 442 

periodic, 443 

progressive systematized, 443 
Inspection, general methods, 44 

in diseases of stomach, 139 
Interstitial nephritis (v. nephritis) , 

376 
Intertrigo, 404 

Intestinal catarrh, acute (v. dysen- 
tery), 209 

obstruction, 234 

parasites, 241 

tuberculosis, 227 
Intestines, diseases of, 183 
Intubation, 740 

diphtheria, 740 

nasal, 744 
Intussusception, 233 
Inunctions, 28 

nutritive, 28 
Irrigation of colon, 27 
Ischaemia, 423 
Itch (v. scabies), 416 

Jaundice, catarrhal, 178 

new-born (v. icterus 1, 119 
Junket, 106 

Kernig's sign, 49, 439, 688 
Kidneys, acute degeneration, 

diseases of, 364 
Knee-jerk, 48, 439 
Koplik'^ sign, 636 
Kyphosis, 57S 

Lactic acid in gastric contents, 144 

test for, 144 
Lactobutyrometer, 82 
Lactometer , (Si 

Lactose in modified milk, 88, 90 
La grippe (v. influenza), "7 s 
Laryngismus stridulus, 234 
Laryngitis, acute catarrhal, 156 



766 



INDEX. 



Laryngitis, diagnosis, 257 

etiology, 256 

symptomatology, 256 

therapeutics, 258 

treatment, 258 
Lavage, 21, 148 

contra-indications, 26 

in chronic gastritis, 162 

method of performing, 24 
Leptomeningitis (v. meningitis), 

45o 
Leucocytosis with anaemia, 424 
Leukaemia, 431 

pseudo-, 432 

symptomatology, 431 

therapeutics, 433 

treatment, 433 
Lice (v. pediculosis), 415 
Liebig's food, 107 
Lithaemia. 567 

etiology, 567 

symptomatology, 568 

therapeutics, 571 

treatment, 570 
Lithuria, 569 
Liver, cirrhosis, 180 

diseases of, 177 
therapeutics, 181 
treatment, 181 

examination of, 177 

yellow atrophy, 179 
Lumbar puncture, 458 

diagnostic value, 462 

in meningitis epidemic, 692 

operative technique, 460 
Lymphatism, 122, 586 

Macewen's sign, 53 
Malaria, 694 

blood in, 694 

diagnosis, 698 

etiology, 694 

irregular, 697 

masked, 697 

pathology, 695 

prognosis, 697 

symptomatology, 695 



Malaria, therapeutics, 698 

treatment, 698 
Malarial cachexia, 697 

fever, 694 
Malformations of stomach,' 169 
Malnutrition, 624, 629 

diagnosis, 629 
Malpositions of stomach, 169 
Malt diastase, 107 
Malted milk, Horlick's, no 
Malt extract, 108 
Maltine, 108 
Mania, 442 
Marasmus, 624 

analysis of gastric contents in, 626 
diagnosis, 629 
diet, 630 
etiology, 626 
prognosis, 629 
symptomatology, 627 
therapeutics, 633 
treatment, 629 
Massage, 28 

Mastitis in newborn, 119 
Masturbation insanity, 444 
Measles (v. rubeola) , 635 

German (v. rubeola) , 656 
Melancholia, 443 
Melena, 120 
Mellin's food, no 
Membranous croup, 726, 733 
Meninges, diseases of, 450 
Meningitis, 450 

basilar (v. meningitis, tubercu- 
lous) , 453 
cerebro-spinal, epidemic, 450, 684 
abortive, 687 
complications, 690 
diagnosis, 690 
etiology, 684 
fulminating, 686 
pathology, 685 
prognosis, 690 
protracted, 687 
sequelae, 690 
symptomatology, 686 
temperature in, 689 



INDEX. 



767 



Meningitis, therapeutics, 692 
treatment, 691 
varieties, 686 
leptomeningitis, acute, 450 
diagnosis, 453 
pathology, 451 
prognosis, 452 
symptomatology, 451 
therapeutics, 465 
treatment, 464 
posterior basic, 454, 691 
pseudo-, 507 
tuberculous, 453 
diagnosis, 458 
pathology, 454 
prognosis, 457 
symptomatology, 455 
therapeutics, 467 
treatment, 464 
Methods of clinical examination, 30 

of prescribing, 72 
Microscopical examination of human 
milk, 82 
of stools, 190 
Migraine, 528 
Milk and cream mixtures, 92 

asses' milk compared with human, 

79 
cows', analysis of, 83 
bacteria in, 83 
compared with human, 78 
condensed, no 
digestion of, 183 
"Ideal" testers, 84 
impurities in, 83 
malted, no 
modification of, 86 

barley water in, 94, 105 

cane-sugar in, 88, 90 

diluents in, 90, 94, 105 

formulae, 93 

lactose in, 88, 90 

milk and cream mixtures, 92 

top milk method, 90 
peptonized, 107 
preservatives in, 83 
top milk, 83, 90 



Milk, human, analysis of, 80 
bacteria in, 100 
compared with cows', 78 
composition, 77 
microscopical examination, 82 
strippings, 84 
variations in, 84 
infection, acute (v. cholora infan- 
tum), 204 
sugar in milk modification, 88, 90 
Mitral regurgitation, 356 

stenosis, 357 
Modification of milk, 86 
Morbidity, infant, 30 
Morbilli (v. rubeola), 635 
Morbus maculosus Werlhofii, 436 
Mortality, infant, 31 
Motor affections, 492 
Mouth, care of, 10 
diseases of, 124 
putrid sore, 131 
Mucous disease (v. diarrhoea), 223 
Multiple neuritis (v. neuritis), 524 

sclerosis (v. sclerosis), 523 
Mumps (v. parotitis), 675 
Muscular development in infant>, 36 

dystrophy (v. dystrophy), 517 
Mutton broth, 106 
Mycotic disease (v. thrush), 31, 132 
Myocarditis, 352 
diagnosis, 353 
prognosis, 354 
symptomatology, 353 
therapeutics, 354 
treatment, 354 

Nephritis, acute, 368 
diet, 372 
etiology, 369 
pathology, 369 
prognosis 371 
symptomatology , 370 
therapeutics, 372 
treatment, 371 
varieties, 368 
chronic, 373 

interstitial, 376 



768 



INDEX. 






Nephritis, pathology, 376 
prognosis, 376 
therapeutics, 377 
treatment, 377 
parenchymatous, 374 
pathology, 374 
prognosis, 375 
symptomatology, 374 
therapeutics, 377 
treatment, 377 
Nervous system, diseases of, 438 
Neuralgia, 526 
diagnosis, 527 
therapeutics, 527 
treatment, 527 
Neuritis, multiple, 524 
diagnosis, 525 
symptomatology, 525 
therapeutics, 526 
treatment, 526 
Newborn, apoplexy in, 114 
asphyxia, 112 

sudden death from, 123 
atelectasis, 123 
care of, 9 

diseases of, 31, 112 
erysipelas, 115 
therapeutics, 115 
treatment, 115 
fatty degeneration, acute, 116 
gastro-intestinal haemorrhage, 120 

therapeutics, 121 
gonorrhoea, 121 
haemoglobin uria, 117 
icterus, 119 

intracranial haemorrhage, 114 
mastitis, 119 

therapeutics, 119 
treatment, 119 
oedema, 120 
omphalitis, 115 

ophthalmia (v. ophthalmia), 117 
peritonitis, 115 
sepsis in, 114 

pathology, 114 
sudden death, 122 
tetanus, 115 



Newborn, umbilical arteritis, 115 

phlebitis, 115 
Night terrors, 444 
Noma (v. stomatitis), 134 
Nose, diseases of, 530 

syringing, 19 
Nurse, wet, 86 
Nursing, 9 
Nystagmus, 501 

Oatmeal water, 106 
Objective symptoms, 72 
Obstruction, intestinal, acute, 234 

diagnosis, 236 
OSdema, newborn, 120 

without kidney lesion, 367 
Oligochromaemia, 432 
Oligocythaemia, 432 
Omphalitis, newborn, 115 
Ophthalmia neonatorum. 117 
prognosis, 118 
treatment, 118 
Orange juice, 95 
Organic heart disease, 354 
Orthostatic albuminuria, 365 
Osteochondritis, 620 
Osteogenesis imperfecta, 572 
Otitis, 530 

influenzal, 532 
in scarlatina, 647 
media, acute catarrhal, 532 
diagnosis, 535 
prognosis, 534 
purulent, 532 
symptomatology, 533 
therapeutics, 535, 537 
treatment, 535 
tubercular, 532 
Oxaluria, 385 
Ozaena, 554 

Pack, cold, 19 

hot, 19 

mustard, 19 
Palpation, general methods, 50 

in diseases of stomach, 141 
Palsy, cerebral, 510 



INDEX. 



769 



Palsy, prognosis, 513 

symptomatology, 512 
Paracentesis, 327 
Paralysis, post-diphtheritic, 749 

pseudohypertrophic, 518 

spinal, 515 
Paralytic affections, 510 
Paranoia, 443 
Paraplegia, hereditary spastic, 521 

pathology, 521 

symptomatology, 521 
Parasites in stools, 192 
Parasites, intestinal, 241 

morphology, 243 

therapeutics, 245 

treatment, 244 

varieties, 241 
Parasitic diseases, animal, 415 

vegetable, 412 
Parenchymatous nephritis 1 v. ne- 
phritis), 374 
Parotitis, 675 

diagnosis, 677 

epidemic, 675 

prognosis, 677 

secondary, 676 

symptomatology, 676 

therapeutics, 678 

treatment, 678 
Pasteurization, 102 
Pasteurizer, Freeman's, 102 
Pectus carinatum, 47, 578 
Pediculosis capitis, 415 

definition, 415 

diagnosis, 415 

symptomatology, 415 

treatment, 415 
Peliosis rheumatica 1 v. purpura), 

436 
Pemphigus, 409 
Pepsin, test for, 145 
Peptogenic milk powder, 107 
Peptonized food in prematurity, 15 

milk, 107 
Percentage of food constituents, 97 
Percussion, abdomen, 58 

chest, 54 



Percussion, factors influencing 

general methods, 53 
head, 53 

in stomach diseases, 140 
Pericarditis, 342 
in rheumatism, 611 
pathology, 342 
prognosis, 345 
symptomatology, 343 
therapeutics, 345 
treatment, 345 
Periodic vomiting, 164 
Periods, of childhood, 30 

of infancy, 30 
Peritonaeum, diseases of, 248 
Peritonitis, acute, 248 
pathology, 248 
symptomatology, 249 
therapeutics, 249 
treatment, 249 
chronic (v. tuberculous periton- 
itis), 251 
new-born, 115 
tuberculous, 251 
diagnosis, 252 
prognosis, 252 
symptomatology , 251 
therapeutics, 253 
treatment, 253 
Peritonsillar abscess, 541 
Pertussis, 667 

complications, 671 
diagnosis, 672 
etiology, 667 
pathology, 668 
prognosis, 671 
sequelae, 671 
symptomatology, 6hS 
therapeutics, 673 
treatment, 672 
Petit mal, 478 
Petrissage, 29 
Phimosis, 387 
Phlebitis, umbilical, 1 15 
Phthisic, chronic fibroid, 306 

pneumonic, 298 

Physical diagnosis, 44 



770 



INDEX. 



Pial haemorrhage, 112 
Pityriasis linguae, 129 
Pleurisy, 319 
diagnosis, 324 
pathology, 320 
physical signs, 322 
prognosis, 325 
symptomatology, 321 
therapeutics, 329 
treatment, 326 
operative, 328 
Pleuro-pneumonia (v. pneumonia) 

295 
Plica polonica, 415 
Pneumonia, abortive, 290 
broncho-, acute, 270 
catarrhal, 270 
central, 289 
cerebral, 288 
croupous (v. lobar) , 283 
influenzal, 290 
lobar, 283 

complications, 290 
diagnosis, 294 
etiology, 283 
pathology, 284 
physical signs, 291 
prognosis, 293 
symptomatology, 285 
therapeutics, 296 
treatment, 296 
varieties, 288 
lobular, 270 
pleuro-, 295 

therapeutics, 296 
treatment, 296 
typhoid, 290 
wandering, 289 
Polioencephalitis, acute 511 
Poliomyelitis, acute, anterior, 515 
diagnosis, 516 
pathology, 515 
prognosis, 516 
symptomatology, 515 
Polyuria, 376, 378, 380, 507 
Prematurity, 14 
diet in, 15 



Prescribing, methods of, 72 
Preservatives in cow's milk, 83 
Prof eta's law, 618 
Pseudo-diphtheria, 725, 734 
Pseudo-hype rtrophic paralysis, 518 
Pseudo-leukaemia, 423, 432 
Pseudo-meningitis, 507 
Ptyalin, test for, 145 
Pulmonary tuberculosis (v. tubercu- 
losis), 297 
Pulse in childhood, 63, 335 
Pump, stomach, 22 
Purpura, 435 

fulminans, 437 

haemorrhagica, 436 

Henoch's, 436 

rheumatica, 436 

simplex, 435 

therapeutics, 437 

treatment, 437 
Pyuria, 385 

Quantity of food in infancy, 98 
Quinsy (v. tonsillitis, parenchyma- 
tous) , 541 

Rachitic rosary, 577 
Rachitis, 572 

acute, 581 

diagnosis, 581 

etiology, 572 

fcetal, 572 

Pasteurized milk in, 104 

pathology, 574 

prognosis, 581 

symptomatology, 576 

teeth in, 128 

therapeutics, 582 

treatment, 582 
Rales, 63 

Record keeping, 41 
Reflexes, 48 
Regurgitation, aortic, 358 

mitral, 356 
Remedies, constitutional, 73 
Renal calculi (v. calculi), 382 
Renal colic, 382 



INDEX. 



771 



Respiration in childhood, 63 

puerile type, 62 
Respiratory tract, diseases of, 254 
Retropharyngeal abscess (v. abscess), 

546 
Rheumatic fever, 606 
Rheumatism, 606 
anaemia in, 612 
articular, 606, 610 
chorea in, 612 
chronic, 612 
diet, 613 

endocarditis in, 610 
etiology, 607 
gastralgia in, 612 
hemicrania in, 612 
muscular, 611 
pericarditis in, 611 
symptomatology, 609 
therapeutics, 613 
tonsillitis in, 537, 611 
treatment, 613 
Rhinitis, acute, 548 

symptomatology, 549 

therapeutics, 551 

treatment, 550 
atrophic, 554 

etiology, 554 

prognosis, 556 

symptomatology, 555 

therapeutics, 558 

treatment, 557 
chronic, simple, 552 

symptomatology, 553 

therapeutics, 558 

treatment, 556 
hypertrophic, 553 

etiology, 554 

prognosis, 556 

symptomatology, 555 

therapeutics, 558 

treatment, 556 
pseudo-membranous, 550 

therapeutics, 552 

treatment, 551 
purulent (v. chronic), 552 



Rice water, 105 

paste, 105 
Rickets (v. rachitis) , 572 
Ringworm (v. tinea circinata) , 413 
Rotheln (v. rubella), 656 
Rubella, 656 

diagnosis, 657 

etiology, 656 

morbilliforme, 656 

prognosis, 657 

scarlatiniforme, 656 

symptomatology, 656 

therapeutics, 657 

treatment, 657 

varieties, 656 
Rubeola, 635 

blood in, 640 

complications, 640 

desquamation, 639 

etiology, 635 

symptomatology, 636 

temperature in, 639 

therapeutics, 641 

treatment, 640 
Rupture (v. hernia) , 235 

Sabre-blade deformity, 620 

Saint Vitus' dance (v. chorea), 492 

Scabies, 416 

definition, 416 

diagnosis, 416 

etiology, 416 

pathology, 416 

prognosis, 416 

therapeutics, 417 

treatment, 416 
Scarlatina, 643 

complications, 055 

desquamation, (>4<s 

diagnosis, 650 

diet, 652 

etiology, 644 

laevigata, 

niiliaris, 6 [6 

prognosis, 049 

sequelae, 65s 

symptomatology, <>4.s 



772 



INDEX. 



Scarlatina, temperature in, 646 

therapeutics, 652 

treatment, 650 

variagata, 646 
Scarlet fever (v. scarlatina), 643 
Sclerosis, disseminated, 523 

multiple, 523 
diagnosis, 524 
symptomatology, 523 
therapeutics, 524 
treatment, 524 
Scorbutus (v. scurvy), 584 
Scrofula, 587 

diagnosis, 590 

erethetic, 589 

etiology, 588 

phlegmatic, 589 

prognosis, 590 

symptomatology, 589 

therapeutics, 592 

treatment, 592 
Scurvy, 584 

diagnosis, 585 

etiology, 584 

infantile, 584 

Pasteurized milk in, 104 

symptomatology, 585 

therapeutics, 586 

treatment, 586 
Seat-worms, 243 
Secondary anaemia, 423 
Sepsis in new-born, 114 
Serum therapy, 750 
Shiga's bacillus, 195, 202 
Simple anaemia, 423 
Skin, diseases of, 393 
Sleep, 11 

Small-pox (v. variola) , 658 
Snuffles, 619 
Sore mouth, putrid, 131 
Spasm, congenital gastric, 173 

glottis, 254 
prognosis, 254 
symptomatology, 254 
treatment, 255 
Spasmus nutans, 501 



Spasmus nutans, prognosis, 502 

treatment, 502 
Spastic paraplegia, 521 
Splenic anaemia (v. leukaemia), 431 
Sponging, cold, 13 
Spotted fever, 450, 684 
Spraying, throat, 20 
Status choreicus, 498 

lymphaticus, 122, 586 
Stenosis, aortic, 358 
mitral, 357 
pyloric, 170 
stomach, 169 
Sterilization of food, 101 
Sterilizer, Arnold steam, 102 
Stethoscope, binaural, 60 

monaural, 60 
Stiller's phenomenon, 47 
Still's disease, 612 
Stimulants, use of, 70, 109 
Stomach, atresia, 169 
cancer, 176 
contraction of, 170 
dilatation, 170 
diagnosis, 173 
etiology, 171 
symptomatology, 173 
treatment, 174 
diseases of, 137 
absorption of food in, 145 
auscultation in, 140 
etiology, 137 
inspection in, 139 
mensuration in, 140 
motility of, 145 
palpation in, 141 
percussion in, 140 
vomiting in, 141 
malformations, 169 
malpositions, 169 
stenosis, 169 

pyloric, 170 
tube, 21 
ulcer, 175 

follicular, 175 

round perforating, 175 

symptomatology, 176 






INDEX. 



773 



Stomach, ulcer, therapeutics, 176 

treatment, 176 

tuberculous, 175 
washing out (v. lavage :, 21 
Stomatitis, aphthous, 129 

etiology, 129 

pathology, 130 

symptomatology, 130 

therapeutics. 135 

treatment, 134 
catarrhal, 128 

etiology, 128 

symptomatology, 128 

therapeutics, 135 

treatment, 134 
gangrenous, 134 

etiology, 134 

pathology, 134 

prognosis, 134 

symptomatology, 134 

therapeutics, 135 

treatment, 134 
parasitic, 132 

diagnosis, 133 

etiology, 132 

pathology, 132 

prognosis, 133 

symptomatology, 133 

therapeutics, 135 

treatment, 134 
ulcerative, 131 

etiology, 131 

pathology, 131 

symptomatology, 132 

therapeutics, 135 

treatment, 134 
Stone (v. calculi), 382 B 
Stools, bloody, 187, 192 
analysis of, 188 
color, 185, 188 
decrease in number, 187 
frequent, 186 
in cholera infantum, 20b 
in constipation, 231 
in fermental diarrhoea, 208 
in dysentery, 211 
in ga-tro-intestinal catarrh, 224 



Stools, in indigestion, acute, 197 

in intestinal tuberculosis, 229 

in marasmus, 628 

large, 185 

liquid, 186 

microscopical examination, 190 

mucous, 187 

normal infantile, 184 

parasites in, 192 

pus in, 192 
Stridor, congenital, 254 
Strippings, 84 
Strychnia, use of, 71 
Subjective symptoms, 72 
Sudden death in infants, 122 
Symptomatic nervous affections, 52b 
Symptoms, objective. 72 

subjective, 72 
Syphilis, 617 

acquired, 617 

congenital, 617 

germinal, 617 

hereditary, 617 
diagnosis, 621 
pathology, 618 
prognosis, 621 
symptomatology, 619 
therapeutics, 622 
treatment, 622 
Syringing, nasal, 19 
Syringomyelia, 521 

diagnosis, 522 

prognosis, 522 

symptomatology, 522 

Tabes mesenterica. 228 

Tache" cerebrale, 45, 53, 45b, 507 

Talipes equinus, 516 

Tape-wornis, 242 

Teeth, abnormalities, 127 

care of, 10 

Hutchinson, 127 

in rachitis, 12S 
Temperament, 38 
Temperature in rubeola, 639 

in scarlatina, b46 

normal, 66 



774 



INDEX. 






Test-meal, 143 
Tetanus, 115 
antitoxin, 116 
therapeutics, 116 
treatment, 116 
Tetany, 489 
diagnosis, 491 
etiology, 489 
prognosis, 491 
symptomatology, 490 
therapeutics, 491 
treatment, 491 
Tetter (v. eczema) , 394 
Therapeutics, general methods, 69 
Throat, diseases of, 530 

spraying, 20 
Thrush, 31, 132 
Thymic death, 122 
Tinea, 411 
circinata, 413 
diagnosis, 414 
etiology, 414 
prognosis, 414 
symptomatology, 414 
therapeutics, 414 
treatment, 414 
tonsurans, 412 
definition, 412 
diagnosis, 412 
etiology, 412 
pathology, 412 
prognosis, 412 
symptomatology, 412 
therapeutics, 413 
treatment, 413 
Tonsillitis, acute, 537 

cryptic (v. folliculous) , 538 
folliculous, acute, 538 
diagnosis, 539 
symptomatology, 539 
therapeutics, 540 
treatment, 540 
parenchymatous, acute, 541 
prognosis, 542 
symptomatology, 542 
therapeutics, 543 
treatment, 542 



Tonsillitis, rheumatic, 537, 611 
superficial, acute, 538 

symptomatology, 538 
ulcero-membranous, 541 
therapeutics, 541 
treatment, 541 
Tonsillotomy, operative technique, 

545 
Tonsils, hypertrophy, 543 
etiology, 544 
symptomatology, 544 
therapeutics, 545 
tonsillotomy in, 545 
treatment, 544 
Top milk, 83, 90 
Torticollis, 611 

Tracheotomy, in diphtheria, 740, 744 
Trousseau's symptom, 490 
Tuberculin, 303 
Tuberculosis, 595 
chronic, 602 
congenital, 597 
diagnosis, 604 
diet in, 605 
etiology, 595 
intestinal, 227 
pathology, 228 
prognosis, 229 
symptomatology, 229 
therapeutics, 230 
treatment, 230 
latent, 597 
miliary, 297 
acute, 601 
pathology, 598 
protracted, 602 
pulmonary, caseous, 298 
. diagnosis, 301 
pathology, 298 
prognosis, 300 
symptomatology, 299 
therapeutics, 302 
treatment, 303 
chronic, 303 
diagnosis, 309 
diet, 312 
prognosis, 308 



INDEX. 



775 



Tuberculosis, symptomatology, 305 
therapeutics, 312 
treatment, 310 
fibro-caseous, 303 
symptomatology, 600 
therapeutics, 604 
treatment, 604 
Tuberculous adenitis (v. adenitis), 

587, 59i 
diathesis, 595 

meningitis (v. meningitis), 453 
peritonitis (v. peritonitis), 251 
Typhoid fever, 700 
abortive, 709 
blood in, 708 
complications, 709, 712 
diagnosis, 712 
diet, 716 
eruption, 707 
etiology, 700 
hydrotherapy, 717 
lesions, 700 
pathology, 703 
pneumonia, 290 
prognosis, 711 
pulse, 708 
relapses, 709 
septicaemic, 704 
symptomatology, 704 
temperature, 704, 706, 711 
therapeutics, 720 
treatment, 716 
urine in, 708 

Uffelman's test, 144 

Ulcer of stomach, 175 

Uraemia, 375 

Uric acid diathesis ( v. lithasmia) , 567 

Urinary tract, diseases of, 364 

Urine, blood in, 367 

in cholera infantum, 206 

in cyclic vomiting, 165 

in cystitis, 385 

in diabetes insipidus, 378 
mellitus, 579 

in diagnosis, 66 

in epilepsy, 483 



Urine, in hysteria, 507 

in kidney disease, 364 

in lithaemia, 569 

in nephritis, acute, 370 
chronic interstitial, 376 
parenchymatous, 374 

in scurvy, 585 

in tuberculosis, pulmonary, 308 

in typhoid fever, 708 

in yellow atrophy of liver, 179 
Urticaria, 409 

diagnosis, 410 

etiology , 410 

papulosa, 410 

pigmentosa, 410 

prognosis, 411 

symptomatology, 410 

therapeutics, 411 

treatment, 411 

Vaccination, 662 

operative technique, 662 
Vaccine lymph, 663 
Vaccinia, 661 

prognosis, 664 

symptomatology, 663 

therapeutics, 665 

treatment, 665 
Vaginitis (v. vulvovaginitis) , 390 
Valvular heart disease, chronic, 354 

prognosis, 356 

stages, 355 

symptomatology, 354 

therapeutics, 360 

treatment, 359 
Varicella, 665 

diagnosis, 666 

etiology, 665 

gangrenosa, 666 

symptomatology, 665 

therapeutics, '167 

treatment, 667 
Variola, 658 

diagnosis, 6bo 

etiology . 

pathology, '>.s< s 

prognosis, 660 



776 



INDEX. 



Variola, symptomatology, 658 
therapeutics, 661 
treatment, 660 
Varioloid, 660. 
Ventilation, 12 
Vernix caseosa, 9 
Vesical calculi (v. cystitis), 384 
Volvulus, 235 
Vomiting, cyclic, 142, 164 
prognosis, 166 
symptomatology, 165 
therapeutics, 166 
treatment, 166 
in stomach diseases, 141 
periodic, 164 



Vulvo-vaginitis, 390 
.non-specific, 390 
specific, 391 
therapeutics, 392 
treatment, 392 

Weaning, 95 
Weight chart, 36 

curve, 36 
Wet nurse, 86 

Whooping cough (v. pertussis), 667 
Widal's test, 713 

Winkel's disease (v. hemoglobi- 
nuria), 117 
Worms (v. parasites), 241 



FES 10 1906 






>• 





mt 



W, 



.^J* 



*S 




*»»*V 



v 



' >y 



9 






,C\tV *.- r" 



